Title: RECORDS MANAGEMENT AND RETENTION - … RECORDS MANAGEMENT AND RETENTION . Scope: ... third-party access to SHS records is required for purposes of continuity of patient care

APPENDIX A – Sample Document Management and Retention Policy

SAMPLE HEALTH CARE SYSTEM

Administrative/

Corporate Compliance/ Legal Services

Title: RECORDS MANAGEMENT AND RETENTION

Scope: This policy applies to all Sample Health System (SHS) employees with responsibilities for the creation, use, maintenance, retention, preservation and disposal of SHS records.

Policy Statement: a. It is SHS’ policy to apply effective and cost efficient management

techniques to maintain complete, accurate, and high quality records.

b. Records shall be retained in accordance with all applicable laws and regulations and this policy. Where regulations are vague or unclear, SHS policy is to attempt to fully comply with all applicable rules and regulations in a manner consistent with health industry standards.

c. Records that have satisfied their required period of retention and are no longer required shall be destroyed in an appropriate manner consistent with this policy.

d. Retention periods are ordinarily set as short as possible to minimize storage expense. Whenever lawful and feasible, less expensive alternatives to the storage and maintenance of paper records shall be considered.

e. All SHS employees and agents shall be responsible for ensuring that all SHS records are created, used, maintained, preserved and destroyed in accordance with this policy.

f. SHS’ access to or ownership of SHS records shall be appropriately protected in all divestitures of property or lines of business or facility closures. If third-party access to SHS records is required for purposes of continuity of patient care or continuity of operations, appropriate steps shall be taken to ensure that SHS’ original records are maintained and controlled by SHS at the conclusion of such process, in a manner consistent with this policy.

g. In order to simplify the processes by which SHS records are placed in long-term storage facilities, the Records Management Committee shall identify those storage locations outside of SHS facilities that are approved for off-site storage and retention of SHS records. No other locations will be used by SHS.

h. SHS records maintained on SHS sites shall be maintained in a manner consistent with the storage requirements specified by the Records Management Committee.

RECORDS RETENTION & MANAGEMENT Page 1 of 83 Administrative/Corporate Compliance

i. Records designated by the Records Management Committee as Class A [Permanent] shall be securely maintained, controlled and protected to prevent unauthorized access. Permanent sign-in and checkout logs for all Class A records shall be maintained by the SHS department responsible for storage of Class A records. In addition, whenever feasible, Class A records shall be duplicated in an appropriate designated off-site storage facility situated 25 or more miles from the primary permanent storage location, preferably in both analog and digital formats.

j. Records classified as less than permanent shall be maintained, stored and destroyed in accordance with their designated classification. Records that are not required to be retained according to the Records Retention Guide shall be routinely destroyed in a manner consistent with approved methods of destruction as specified by the Records Management Committee.

k. If SHS is served with a subpoena, search warrant, or similar official request or if there is reason to believe that SHS may be served with a subpoena, search warrant, or similar official request, the department responsible for the storage and retention of such records shall immediately halt any planned destruction or transfer of such records and shall comply with the SHS Subpoena Policy.

l. If SHS is the subject of a government investigation, or the Corporate Compliance Office has reason to believe it may be the subject of an impending investigation, the Corporate Compliance Office and/or departmental leaders with knowledge of such investigation shall direct the immediate safeguarding of records that appear to be relevant to that investigation. Unless otherwise specified, the Subpoena Policy shall control pending completion of such investigation.

m. To obtain any exception from this policy, there must be a written plan approved by the SHS Corporate Compliance Office and/or Records Management Committee that assures compliance with the basic objectives of this policy.

n. All records generated and received by SHS are the property of SHS. No SHS employee, by virtue of his or her position, has any personal or property right to such records even though he or she may have developed or compiled them, including but not limited to SHS records created on home or non-SHS computer equipment used by SHS employees for work-related purposes.

o. The unauthorized copying, transfer, dissemination, destruction, removal or use of SHS records is prohibited.

p. Information pertaining to unauthorized destruction, removal or use of SHS records or regarding falsification or alteration of information in any SHS record or document should be reported to the Corporate Compliance Office, either directly or through the Compliance Line at YYY-YYY-YYYY.


Special Instructions:

1. SHS has contracted with Iron Mountain for off-site storage of records. Contact the Corporate Compliance Office for the Iron Mountain representative.

Responsibilities:

I. Corporate Compliance will have overall responsibility in the implementation of this policy.

II. Records Management Committee will:

A. Evaluate the legal requirements applicable to each record type encountered within SHS operations, and specify the records retention period applicable to such record types. The SHS Records Retention Guide is updated periodically and is published on the SHS Intranet as an attachment to this policy.

B. Consists of appointed representatives from the following departments or divisions of SHS:

1. Corporate Compliance

2. Health Information Management

3. Information Services

4. Finance

5. Legal Services

6. Such other departments or divisions as the Committee shall determine.

C. Establish approved methods and processes for on-site storage of SHS records and files, consistent with applicable law.

D. Evaluate and approve any proposed off-site records storage or retention facility or process.

1. A list of approved off-site records storage sites and vendors will be maintained by the Records Management Committee and posted on the SHS Intranet. Printed copies are available through the Corporate Compliance Office.

E. Establish approved methods of destruction of SHS records and files and the maintenance of appropriate records documenting such destruction.

III. Legal Services Department will:

A. Provide counsel to SHS and the Records Management Committee regarding records retention, records handling, privacy, security and confidentiality designations and legal and statutory requirements for


IV. Health Information Management (HIM) will:

A. Oversee development and maintenance of processes for the storage of all medical and patient-care records generated by SHS.

V. Information Services (IS) will:

A. Oversee development and maintenance of processes for the storage and retention of all electronic records generated by SHS systems.

VI. Financial Services will:

A. Oversee development and maintenance of processes for the storage and retention of all financial records generated by SHS.

VII. Department / Division Directors will:

A. Be separately responsible for appointment of Record Coordinators and development and maintenance of processes for the storage and retention of each respective department’s or division’s records.

1. Designated Record Coordinators are assigned by functional areas and are noted on the Records Retention Guide. Departments responsible for management of records shall advise the Records Management Committee of changes in designation of the Record Coordinator role within or among departments.

Procedure:

I. Development of Records Retention Schedules:

A. All records will be maintained and retained in accordance with Federal and state laws and regulations. Minimum retention schedules are set forth in the Records Retention Guide. The Records Management Committee will review the appropriateness of these retention schedules periodically and recommend modifications as necessary.

1. The Records Retention Guide will be revised and updated to ensure regulatory compliance and reflect revisions in recordkeeping responsibilities. All revisions must be reviewed and approved by the Director of Corporate Compliance and Records Management Committee prior to distribution or publication on the SHS Intranet site.

2. If a designated Record Coordinator cannot readily determine which “Record Type” applies to a particular record, the Records Management Committee will assist the Record Coordinator in identifying the appropriate existing record type and/or in creating an appropriate new record type applicable to the record.

3. Retention Period – The retention period specified generally begins to run upon creation or receipt of the record. However, if a record is created or received in conjunction with an ongoing process (e.g., application, contract, lease, lawsuit, RFP) or project (e.g.,


4. Active/Inactive Records are to be reviewed periodically to determine if they are active or inactive. Records that are no longer required as active will be reviewed and assessed for storage in a designated offsite storage facility. Duplicate, multiple and transitory record materials are not to be sent to the designated offsite storage facility, but should be destroyed. Whenever possible, the official record is the one that will be retained according to this policy.

II. Records Retention:

A. Offsite Storage Facilities:

1. SHS contracts with commercial offsite storage facilities to store, control and protect inactive records. To the extent that they have access to SHS records, the commercial offsite storage facilities must agree to maintain the confidentiality of SHS’ records.

2. Offsite storage facilities are to be in secure locations that safeguard the records from the following:

a. Ordinary hazards, such as fire, water, mildew, rodents and insects;

b. Man-made hazards, such as theft, accidental loss, sabotage, and commercial espionage;

c. Disasters, such as fire, flood, earthquakes, hurricanes, wind, and explosions; and

d. Unauthorized use, disclosure and destruction.

3. Offsite storage facilities are to provide proper vault storage with temperature and humidity controls for electronic, audio/video, and microfilm storage.

4. Record storage containers are to be standard 12”x15”x10” boxes, unless the records require a special-sized box.

5. Records series stored in the standard boxes must be adequately described and include the following information in order to facilitate their reference, review and destruction:

a. The inclusive dates;

b. Originating department and department number;

c. Type of media;

d. Retention code and title; and

e. Contact name and telephone number.


III. Vital Records Storage:

A. Vital records are to be duplicated onto appropriate media and the duplicate records stored in the designated offsite storage facilities, for reconstructive use in the event of a natural or man-made disaster.

B. All facilities including, but not limited to, hospitals, ambulatory surgery centers, home health agencies, physician practices, and all corporate departments are to maintain current lists of vital business records and forward copies of the lists to the Finance Administration Department which maintains a master list of vital business records for SHS. All facilities including, but not limited to, hospitals, ambulatory surgery centers, home health agencies, and physician practices are to maintain current lists of vital medical records.

IV. Electronic Records Storage:

A. SHS will select appropriate media and systems for storing records which meet the following retention requirements:

a. Permit easy retrieval in a timely fashion;

b. Facilitate distinction between record and transitory record material; and

c. Retain the records in a usable format until their authorized disposition date.

B. SHS will consider the following factors before selecting a storage medium or converting from one medium to another:

a. The approved retention period for the record;

b. The maintenance necessary to retain the records;

c. The access time to retrieve stored records;

d. The portability of the medium (selecting a medium that will run on equipment offered by multiple manufacturers) and the ability to transfer the information from one medium to another;

e. SHS will avoid the use of floppy disks for the exclusive long-term storage of records with retention exceeding three years;

f. SHS will ensure that all authorized users can identify and retrieve information stored on diskettes, removable disks, or tapes by establishing or adopting procedures for external labeling;

g. SHS will establish a process to randomly check storage media based on industry standards to ensure that information is not lost due to changing technology or deterioration by converting storage media to provide compatibility with current hardware and software. Before conversion to a different medium, SHS will determine that the authorized disposition of the electronic records can be implemented after conversion;


h. SHS will backup electronic records on a regular basis to safeguard against the loss of information due to equipment malfunctions or human error;

i. SHS will not permit smoking or eating in electronic media storage libraries and test or evaluation areas which contain long-term records; and

j. External labels for electronic recording media used to store long-term records will provide unique identification for each storage medium, including: the name of the organizational unit responsible for the data; system title, including the version number of the application; special security requirements or restrictions on access, if any; and software in use at the time of creation.

k. In addition, the following information will be maintained for each medium used to store long-term electronic records:

1.) File title;

2.) Dates of creation;

3.) Dates of coverage;

4.) The recording density;

5.) Type of internal labels;

6.) Volume serial number, if applicable;

7.) The number of tracks;

8.) Character code/software dependency;

9.) Information about block size;

10.) Sequence number, if the file is part of a multi-media set; and

11.) Operating system and OS version number.

l. The electronic media will be stored in an offsite location that is secure from unauthorized access and has a temperature, humidity and static-controlled environment.

V. Microfilm Storage:

A. The use of film media for record storage and retention purposes is to be selective and ensure cost effectiveness. Film media includes microfilm, microfiche, computer output microfiche/microfilm, or other similar types of media.

B. To ensure authenticity of the documents filmed, the American National Standards Institute’s (ANSI) guidelines for microfilming documents will be followed.

C. Microfilm storage for long-term records retention purposes will follow the ANSI requirements for packaging, handling, and temperature and humidity-controlled environment. The facility will be an offsite location


VI. Records Destruction:

A. Records that have satisfied their legal, fiscal, administrative, and archival requirements may be destroyed in accordance with the Records Retention Schedules.

B. Records that cannot be destroyed include records of matters currently subject to governmental audit or in litigation, or records with a permanent retention. In the event of a lawsuit or government investigation, the applicable records that are not permanent cannot be destroyed until the lawsuit or investigation has been finalized. Once the litigation/investigation has been finalized, the records may be destroyed in accordance with the Records Retention Schedules.

C. When feasible, SHS will use recycling as the method to destroy records. The designated recycling company will guarantee that the records were destroyed and are no longer recognizable as records. The recycling company will sign a Certificate of Destruction form (Attachment B or provided by contracted storage service) indicating the types and quantities of records destroyed, the method of destruction, the destruction date, and agreeing to maintain the confidentiality of the documents it destroys.

VII. Divestiture or Closure of Facilities/Practices:

A. Divestiture of a Facility – In the event a facility or a line of business is sold, the Legal Department must ensure that sales documents will protect SHS’ right to access SHS business and medical records and will stipulate the protection of SHS’ records as appropriate. Additionally, before divestiture, all electronic records must be backed up and transferred to Information Systems. Also, unless the sales documents specify otherwise, software documentation must be transferred to Information Services. Duplicate copies of patient medical records may remain with the facility to ensure continuity of patient care. Consistent with the overall retention policy, no records will be disposed of until the period of retention has expired for such records.

B. Closure of a Facility – In the event a facility is closed, all facility business records must be transferred to SHS and all facility electronic records must be backed up and transferred to Information Systems. Additionally, software documentation must be transferred to Information Systems. Patient medical records must be transferred to another facility or state archives in accordance with state requirements. Consistent with the overall retention policy, no records will be disposed of until the period of retention has expired for such records.

VIII. Exceptions Reporting Mechanism:

A. In the event that an employee believes another employee, a


IX. Definitions:

Records:

1. A record is any recorded information, regardless of medium or characteristic, which can be retrieved at any time in any retrievable format. This includes all original documents, papers, letters, x-rays, cards, books, maps, photographs, blueprints, sound or video recordings, microfilm, magnetic tape, electronic media and other information recording media, regardless of physical form or characteristic that are generated and/or received in connection with transacting business and related to SHS’ legal obligations. If not stipulated otherwise, this is the record to which retention schedules apply.

a. The Records Management Committee maintains a comprehensive schedule of records by usage type, as set forth in the SHS Records Retention Guide. The Records Retention Guide is maintained and updated on an annual or more frequent basis.

2. Medical or patient records include clinical data as well as patient demographic, clinical research and financial data. In certain circumstances, analog data generated in conjunction with patient care is transferred into digital format for purposes of incorporation within the patient care record, at which point the digital record, when authenticated, becomes the primary record and the analog data may be destroyed in accordance with departmental policy.

3. Records can only be discarded when the specified retention period has expired and a Certificate of Destruction form is executed in accordance with this policy.

Transitory Records:

1. Transitory Records include duplicate copies of correspondence, duplicate copies of records used for short-term reference purposes, blank forms, stocks of publications, magazines, publications from professional organizations, newspapers, public telephone directories, and transitory messages used primarily for the informal communication of information. Transitory messages do not set policy, establish guidelines or procedures or certify a transaction or become a receipt. Transitory messages may include, but are not limited to, e-mail messages with short-lived or no administrative value, voice mail, self-sticking notes, and telephone messages.


a. Transitory records are maintained only for as long as administratively needed, and the retention schedules do not apply EXCEPT in the case of subpoena or governmental investigation, in which event transitory records must be retained pending completion of such processes. Transitory records may be discarded when the need for retention has ended and there is no legal or governmental process pending with regard to such records.

b. Discretion should be used in determining whether to generate or retain transitory messages in the nature of notes of unofficial meetings, telephone conversations or other personal notes. If generated, such records should be routinely discarded when they are no longer useful. For example, when the informal record, such as an employee’s personal notes, is transferred to a more formal record, such as an incident report, the notes are no longer useful and should be discarded. Preliminary working papers and superseded drafts, particularly after subsequent versions are finalized, should be discarded. E-mail that contains no substantive data, such as invitations to lunch and responses to such, should be routinely discarded.

E-Mail Communications:

1. E-mail communications are electronic communications sent from the sender to the recipient using computer workstations or other electronic means, by which the recipient has the ability to open and read the message and identify the subject matter and/or sender.

a. Messages and documents transmitted by e-mail are similar to paper documents. They may be considered business records and to that extent may be subject to this policy. Email may also be transitory and not subject to formal retention schedules. To determine whether an e-mail message must be retained and for how long, think of it like a paper memo or document. If you would retain a memo due to its content, then you are required to retain an e-mail message of the same content for the same length of time.

b. The originator/sender of the e-mail message (or the recipient of a message if the sender is outside the Company) is the person responsible for retaining the message. E-mail messages may be retained in electronic form in the mailbox, or be printed and filed along with other documents related to the same topic or project. Users may delete e-mail messages that they are not required by this policy to retain (such as transitory messages) and messages that are being retained in printed form. Other records maintained on electronic media (except e-mail) must be maintained in accordance with this policy.



Related Policies:

SHS P & P: “Subpoenas”

SHS P & P: “Contract Management”

Related Forms: Certificate of Records Destruction (attached)

References:

SHS Records Retention Guide as published by the SHS Records Management Committee. The most current version is attached to this policy.

Washington Uniform Health Information Practices Act, RCW Chapter 70.02

Health Insurance Portability & Accountability Act of 1996 [HIPAA]

JCAHO Accreditation Manual for Hospitals, Information Management

Approval By: SHS Policy and Procedure PILOT

Date of Approval:

Original Date: Revision Dates: Reviewed with no Changes Dates:

Distribution: SHS Intranet

Sample Health System Attachment A –Document Retention Schedule Page 12.


Sample Health System

Document Retention Schedule Version 4.1 May 15, 2008

Table of Contents

Policy & Procedure ...........................................................................................Error! Bookmark not defined.

1. .....................................................................................................................................................................15 Administrative Records

1.1. ............................................................................................................................................. 15 Management1.1.1.1. ....................................................................................................................................... 17 Admitting1.1.1.2. ............................................................................................................................. 18 Central Services1.1.1.3. ...................................................................................................................... 19 Clinical Engineering1.1.1.4. ............................................................................................................................................ 19 Clinics1.1.1.5. ....................................................................................................................... 19 Emergency Services1.1.1.6. ................................................ 20 Engineering & Construction Services – Property and Equipment1.1.1.7. ................................................................................................................................ 21 Housekeeping1.1.1.8. .................................................................................................................................. 22 Home Health1.1.1.9. .......................................................................................................................................... 22 Imaging1.1.1.10. ............................................................................................. 24 Laboratory, Therapy and Imaging1.1.1.11. ....................................................................................................................... 27 Nuclear Medicine1.1.1.12. ...................................................................................................................................... 28 Nursing1.1.1.13. ...................................................................................................................... 29 Nutrition Services1.1.1.14. ........................................................................................................................... 29 Pharmaceutical1.1.1.15. ............................................................................................................ 30 Purchasing & Receiving1.1.1.16. ................................................................................................................. 30 Quality Improvement1.1.1.17 ...................................................................................................................................... 31 Security1.1.1.18 ...................................................................................................................................... 32 Therapy

1.2 ................................................................................................................................................ 32 Operations

1.3 ............................................................................................................................................. 33 Organization

1.4 ............................................................................................................................................... 33 Compliance1.4.1 ..................................................................................................................................................... 33 Audits1.4.2 ..................................................................................................................................................... 33 Ethics1.4.3 ................................................................................................................................................... 34 Reports

1.5 .................................................................................................................................... 34 Human Resources1.5.1.17 .......................................................................................................................................... 37 Benefits1.5.2 ......................................................................................................................... 38 Benefit Plans/Programs1.5.3 ............................................................................................................. 39 Collective Bargain Agreements1.5.4 .......................................................................................................................... 39 Government Reporting1.5.5 ................................................................................................................................... 40 Health and Safety1.5.6 ...................................................................................................................... 40 Personnel Administration1.5.7 ............................................................................................................................ 41 Salary Administration1.5.8 ....................................................................................................................................... 42 Personnel Files1.5.9 ................................................................................................................................ 42 Personnel Selection1.5.10 .............................................................................................................................................. 42 Training

1.6 ............................................................................................................................... 43 Information Services



1.7 .......................................................................................................................................................... 46 Legal1.7.1 ........................................................................................................................... 47 Business-Organization1.7.2 ............................................................................................................................ 47 Contracts/Agreements1.7.3 ............................................................................................................................................... 49 Corporate1.7.4 ............................................................................................................. 49 Copyrights/Trademarks/Patents1.7.5 .................................................................................................................................. 49 Insurance Records1.7.6 ............................................................................................................................... 52 Intellectual Property1.7.7 ................................................................................................................................... 52 Litigation/Claims1.7.8 .................................................................................................................................................. 52 Projects1.7.9 ............................................................................................................................................. 52 Real Estate

1.8 ................................................................................................................................................. 53 Marketing1.8.1 ............................................................................................................................................ 54 Advertising1.8.2 ............................................................... 55 Consulting Nurse & Health Information & Referral Services1.8.3 ..................................................................................................................................... 55 Public Relations

1.9 ............................................................................................................................................. 55 Philanthropy1.9.1 ........................................................................................................................................ 55 Grant Records1.9.2 ............................................................................ 55 Fund Raising – We need a retention period for these1.9.3 ........................................................................................ 55 Events- We need a retention period for these

1.10 Physician Services.........................................................................................Error! Bookmark not defined.

2.0 ................................................................................................................................................................................................55 Finance

2.1 ................................................................................................................................................ 55 Accounting2.1.1 .................................................................................................................................................. 55 Banking2.1.2 ..................................................................................................................................... 56 Capital Property2.1.3 ................................................................................................................................................... 57 General2.1.4 ......................................................................................................................................... 59 Intercompany2.1.5 .................................................................................................................................... 59 Journals/Ledgers2.1.6 .................................................................................................................................................... 60 Payroll

2.2 ................................................................................................................................ 61 Accounts Receivable

2.3 ..................................................................................................................................... 63 Accounts Payable

2.4 ....................................................................................................................... 64 Business Office – Revenue

2.5 .............................................................................................................. 73 Reimbursement – Cost Reports

2.6 ............................................................................................................................................................. 73 Tax

3.0 Patient Specific Records................................................................................................................................ 75

4.0 .......................................................................................................................................................................................79 Medical Staff

4.2 ................................................................................................................................. 80 Residents & Fellows

5.0 Research.................................................................................................................................................................................................80

HOW TO USE THIS GUIDE

Each document type has been assigned a retention classification as follows: SHS Document Retention Classifications: Class A = Permanent Class B = 25-Year Records Class C = 15-Year Records Class D = 10-Year Records



Class E = 5-Year Records Class F = Adult Health Information – 10 Years from Last Encounter Class G = Minor Health Information – Patient Age 22 or 10 Years from Last Encounter, whichever is longer Class H = Discretionary, Destroy when No Longer Needed KEEP ALL RECORDS RELATED TO KNOWN AUDITS OR LITIGATION If you cannot find your document type through the index or by using the “Edit” and “Find” function, contact XXXXX at extension ***** or YYYYY at extension ****** and they will bring your concerns to the attention of the Document Retention Committee. The goal is to include a line reference to every document type in use at SHS. The document classification schedule is included on each page of this guide in a footer. If you have difficulty seeing the footer, you may need to select “View” and “Page Layout” in the control bar.


SHS Document Retention Classifications: KEEP ALL RECORDS RELATED TO KNOWN AUDITS OR LITIGATION Class A = Permanent Class B = 25-Year Records Class C = 15-Year Records Class D = 10-Year Records Class E = 5-Year Records Class F = Adult Health Information – 10 Years from Last Encounter Class G = Minor Health Information – Patient Age 22 or 10 Years from Last Encounter, whichever is longer Class H = Discretionary, Destroy when No Longer Needed


1. Administrative Records

1.1. Management

Record Type Retention Class Legal Citations

Accreditation Surveys and Reports Records related to accreditation surveys and results. Includes inspection reports by accrediting institutions, notices of corrections, correction reports, activity calendars, in-house surveys, and testing done prior to the actual accreditation survey.

D RCW 70.41.030; WAC 246-320-025

Administrative Offices OSHA Records; Records include logs, summaries, and OSHA forms 102/102a.

E 29 CFR 1904.6

Administrative Records—Executive Management Files Administrative records from Executive Officers.

D

Administrative Support Records Copies of records which are used for internal administrative activities including records that document procedures, expenditure of funds, day-to-day management of office personnel, supplies, office services and equipment requests.

E

Annual Report to the Community

A

Annual Reports to State Departments of Health

A WAC 246-454-050

Aviation Permits FAA permits for flight operations (Helipads, etc.)

B 14 CFR

Business Permits Records of rights obtained from government permitting certain business activities.

B

Calendar Books Documentation of personal schedules for company employees.

E

Chronological Files Files arranged in chronological order, generally maintained for the convenience of the author. This series applies only to duplicates of original records.

E

Correspondence Files containing copies of letters and memoranda sent to others and original letters and memoranda received from external sources/parties that cannot be placed in more specific categories.

E

Daily Census Daily patient census data.

D

Diaries (Work) & Personal Calendars

E

Directives Records documenting, explaining, or interpreting policies and procedures.

D

Disaster Recovery Plans Records describing the procedures for continuing the operation of the organization in the event of a disaster. Includes the vital records program to reconstruct the vital information of the organization.

D

Emergency Action Plans Records describing the procedures to be followed in an emergency.

D 29 CFR 1910.38





Employee Training Records related to employee training provided on hazards and use of pesticides. E

Environmental Permits Records of rights obtained from government permitting certain environmental activities.

A

Hospital Permits Required permits to operate a hospital.

A RCW 70.41.090 (1)

Inspection Reports Reports of inspection by local, state, or federal agents.

D RCW 70.41.120; 10 CFR 30.51

Internal Planning/Forecasting Reports and Work papers Reports and work papers used for internal planning and forecasting.

E

Mail Operations Records documenting the processing of registered mail, insured mail, postage meter activities, UPS, Federal Express, etc.

E

Management Reports Reports and records providing management information, including status reports, progress reports, and weekly/monthly management reports.

E

Meeting Notes/Minutes Notes or minutes from meetings, including department, committee, and project meetings. This series includes oral conversations and telephone calls pertaining to meeting notes/minutes.

E

Minutes of Board of Directors, Executive Committee, Medical Staff Records detailing the proceedings of board of directors, executive committee, and medical staff meetings.

A

Organizational Charts Records showing the structure of the organization, including the positions, titles, and employee names.

E

Pastoral Visitation Log

E

Patient Personal Property Inventory

E

Project Files Documents detailing internal company projects in process.

H

Reading/Subject Files Subject files maintained for the convenience of the author.

H

Record Center Inventory Records listing the type of records, location, responsible party, and other relevant information about records stored in the off-site record center.

A

Record Destruction Records documenting the destruction of records in accordance with the records retention program.

A Legal Liability

Record Retention Schedule Official records retention schedule including legal research, revisions, review comments, approvals, and other related information.

D

Legal Liability





Records Inventory Records detailing information about the records in the organization obtained during the records inventory.

E

Records Transfer Records documenting the movement of records from active to inactive storage.

E

Reference Files Records maintained for reference purposes only.

H

Table of Authorizations Records specifying which individuals in the organization have authority to approve or authorize specified actions.

D

Telecommunication Reports Reports providing department telecommunication detail for long distance and local calls.

E

Transitory Messages Records used primarily for the informal communication of information. Transitory messages do not set policy, establish guidelines or procedures, certify a transaction, or become a receipt. Transitory messages may include but are not limited to e-mail messages with short-lived or no administrative value, voice mail, self-sticking notes, and telephone messages.

H

Transmittal Documents Short-term documents used to transmit information to another record, e.g., transmittal documents for data entry.

H

Travel—Itineraries, Transactions and Reports Travel itineraries for corporate employee travel. Records and reports detailing travel transactions.

E

Vital Records Program Records describing the procedures for continuing the operation of the organization in the event of a disaster by reconstructing the vital information of the organization.

D Legal Liability

Volunteer records Records related to work activities of volunteers at facilities. Includes work schedules, location, duties performed and certification of hospital worker.

D

Zoning Permits Permits issued by government permitting the construction, renovation, or other use of property based upon the government approved zoning plan.

A

1.1.1.1. Admitting


Individual departments may wish to keep copies of the original records, which are kept at the administrative offices. The department should keep duplicate records only as long as the records are used on a regular basis.

E

Air Ambulance Safety Committee Meeting Minutes Records detailing the proceedings of the Air Ambulance Safety Committee.

E





Ambulance Records Records related to the use of an ambulance in transporting patients.

E RCW 18.73.130 (4); RCW 18.73.140

Budget and budget data

H

Admissions/Discharges Register Official register of all patient admissions and discharges

A

Conditions of admission agreements

D

Patient admission reports Annual compilations should be retained permanently.

E Maybe move to

1.1.1.1 Admitting

Statistics on admissions, services and discharges Statistics data compiled into various reports detailing patient admissions, services rendered, transfers, leave of absences, and discharges. Many daily and monthly reports can be destroyed after year-end statistics are compiled.

D

RCW 70.58.270; WAC 246-455-020;

42 USC 1395cc(a)(1)(I)(ii)

Duplicate from 1.1 and 3.1.

Personnel records

Forward to HR when no longer required.

Requisitions

H

Admissions/Discharges Register Official register of all patient admissions and discharges

A

Conditions of admission agreements

D

Patient admission reports Annual compilations should be retained permanently

E

Statistics on admissions, services and discharges Statistics data compiled into various reports detailing patient admissions, services rendered, transfers, leave of absences, and discharges. Many daily and monthly reports can be destroyed after year-end statistics are compiled.

D

RCW 70.58.270; WAC 246-455-020; 42 USC 1395cc(a)(1)(I)(ii)

1.1.1.2. Central Services


Biomedical Waste – Exception Form Records related to the tracking form for which there is no confirmation of delivery and a signed cover letter explaining the generator's efforts in locating the waste and the results of those efforts. The exception form is submitted to the EPA and appropriate state agency.

E

Biomedical Waste Records Records related to training, instruction, proper handling, and disposition of biomedical wastes.

E

Biomedical Waste Shipment Logs Records related to the shipment, weight, waste category, location points, and transporter’s receipt of biomedical waste.

C





Incineration Records, On-site – Acceptance Records Records documenting regulated medical waste to an on-site incinerator for disposal.

E

Incineration Records, On-site – Operating Logs Records related to the date, length, and total weight of medical waste incinerated per cycle.

E

Radioactive Waste Disposal Records Records related to the disposal of radioactive waste and by-products. Includes date, method of disposal, name and address of the waste hauler, amount disposed of, and the name of the staff handling the disposal or transfer process.

A

Radioactive Waste Disposal Records – Non-Sealed Source Records related to the disposal of any radioactive material that is a non-sealed source with a physical half-life of less than 90 days.

A

1.1.1.3. Clinical Engineering

Record Type Retention Class

Legal Citations

Medical equipment logs Records detailing the type, model, location, and usage of medical equipment. Includes maintenance, scheduled function checks and instrument calibration performed in accordance with the manufacturer’s instructions

B

Medical Procedure Manuals Manuals for medical equipment and procedures that are kept within specific facility departments.

D

1.1.1.4. Clinics


Appointment Books Patient appointment books that record the appointment time and patient name.

E

Encounter Statistics Statistical data for clinic encounters.

CY+E

Social Service Confidential Case Histories-Adults Clinic patients social service case histories.

Adults - D after discharge

RCW 70.41.190

Welfare Agency Records-Adults Clinic records related to welfare agencies.

Adults - D after discharge

RCW 70.41.190

Welfare Agency Records-Minors Clinic records related to welfare agencies.

F G

RCW 70.41.190

1.1.1.5. Emergency Services


Emergency department reports.

D

Emergency department logs

B

42 U.S.C. §1395dd; 42 U.S.C.; §1395dd(d)(2)(C)




Emergency department transfer records Hospitals must keep at least 3 years.

E

1.1.1.6. Engineering & Construction Services – Property and Equipment


Air filter maintenance records Regulations require general acute care hospitals, acute psychiatric hospitals, skilled nursing facilities and intermediate care facilities to maintain such records but do not specify retention periods. Records related to the inspection, performance, and maintenance of air filters.

Life of Air Filter + D

Blueprints and Construction Drawings Blueprints and construction drawings detailing the design of company facilities.

A

Building Permits Permits issued by government permitting the construction, renovation, or other use of property.

A

Construction Project Files Work papers and reports related to specific construction projects.

D

Drawings/Blueprints Drawings and blueprints detailing the design of company facilities.

A

Emergency Generator Records Records related to the inspection, performance, maintenance, and repairs of emergency generators.

Life of Generator

+ E

Emergency generator records: inspection, performance, exercising period and repairs Regulations require general acute-care hospitals, acute psychiatric hospitals, skilled nursing facilities, and intermediate care facilities to maintain such records but do not specify retention periods.

Life of Generator

+ D

Equipment Inspection and Maintenance Records Records related to equipment inspections and required maintenance.

E

Equipment Logs Records detailing the type, model, location, and usage of equipment including heating/cooling, outdoor, and office equipment. Does not include medical equipment.

B

Equipment Operating Instructions Records related to manufacturer’s operation instructions.

Life of Equipment + E

Equipment Records

Life of Equipment + D

Inspection Reports of Grounds and Buildings Records related to the inspection reports of facility grounds and buildings.

E

Lease Abstracts Records summarizing leases, often include some detailed information about each lease such as starting date, ending date, property location, landlord name, payments, etc.

D

Maintenance Records Regulations require health facilities to keep maintenance logs but do not specify retention periods. Records documenting the maintenance of property or equipment.

D




Office Improvements Records documenting the design, construction, renovation, or repair of offices.

A

Office Layouts Records documenting the location and placement of furniture and equipment in offices.

E

OSHPD Project Permits and Inspection

E

Permits/Licenses Includes heliport, health permits, boiler permits, fire inspection permits, FCC license, etc.

Retain Until Expiration of Permit or License + E

Property Appraisals Property appraisal documents produced by a third party.

E

Property Inventory Records describing the type, model, and location of property.

A

Purchase orders

D

Real Estate Records Records related to the purchase, sale, and management of real property including land, buildings, and offices.

A

Refer to 2.1.3 for Real Estate Investment Records

Repair Records Records documenting the repair of property or equipment.

D

Space Allocation Records Records documenting the layout of office space.

E

Sterilizers/monthly bacteriological tests Regulations require general acute-care hospitals, acute psychiatric hospitals, skilled nursing facilities, and intermediate care facilities to maintain such records for 1 year.

E

Thermometer charts Regulations require general acute-care hospitals, acute psychiatric hospitals, skilled nursing facilities, and intermediate care facilities to maintain such records for 1 year.

E

Work Orders Work orders related to the inspection, maintenance, and repairs.

E

1.1.1.7. Housekeeping


Autoclave Records

E

Checkout, Transfer, Isolation Records

E

Cleaning Records, Policies and Procedures

E

Exterminator Records

E

Linen Poundage Report

E




1.1.1.8. Home Health 1.1.1.9. Imaging


Credential License and Certification Records Credentials, licenses, and certifications of each person providing diagnostic and therapeutic radiation, imaging, and nuclear medicine services including formal training, on the job education, and continuing educational credits.

D

Echocardiogram Tracings Patient echocardiogram tracing. Includes actual strips generated by echocardiogram monitors and testing devices where a report or interpretation has been recorded in the patient medical record.

F G

RCW 70.41.190

Electroencephalogram Tracings Patient electroencephalogram tracings. Includes actual strips generated by electroencephalogram monitors and testing devices where a report or interpretation has been recorded in the patient medical record.

F RCW 70.41.190

Electromyograms Tracings-Adults Patient electromyogram tracings. Includes actual strips generated by electromyogram monitors and testing devices where a report or interpretation has been recorded in the patient medical record.

F G

RCW 70.41.190

Environmental Exposure Records documenting the results of measurements and calculations used to evaluate the release of radioactive effluents into the environment.

E RCW 70.98.100

Fetal heart monitor strips

G Refer to 3.3

Images of Computed Tomography Images of spot checks for computed tomography x-ray systems.

E or Twice as Long As the Spot Check Cycle, Whichever Is

Longer

WAC 246-225-130 (2) (u) (iii) (H)

Inspections – Radiology Records related to federal, state, and/or consulting physicist's inspections of the radiological services area. Includes tests on protective equipment such as aprons, gloves, and shields, and any actions taken to correct the identified deficiencies.

E

Mammogram File – Single Visit X-ray film that is the ONLY mammogram taken. Retention is for the actual film not the radiologist's interpretation of film. The interpretation is part of the Patient Medical Record. For more than one mammogram see WA-MED-60-06.

D

Mammograms Original mammograms.

D

Mammography – Quality Assurance Records related to the quality assurance for mammography systems. Includes annual review of quality assurance program, documentation of equipment monitoring, checks of quality control items, and any necessary corrections.

E WAC 246-225-160 (2)

Mammography – Quality Control Surveys Survey reports conducted annually to assure that the facility meets specified quality control and equipment standards.

E WAC 246-225-160 (2)





Mammography Facility – Complaint Records Complaints filed by employees or patients against a mammography provider and the results of the accrediting body's investigations.

D

Nuclear Medicine Reports Includes nuclear medicine interpretations, consultations, and procedures.

E

Performance Records Reports issued on each laboratory's performances for the individual Medicare, Medicaid, and CLIA-licensed specialty or sub-specialty of service after a proficiency test is performed.

E 42 CFR 493.903

Planned Special Exposure Records documenting planned and authorized radiological exposure.

D

Radiation Detection Instrumentation Records related to the calibration of radiation detection instruments that measure the radiation levels in the environment, on humans, and objects. Includes dates and times of inspections, repairs, and dates in and out of service.

E WAC 246-225-130 (2) (u) (ii) (F)

Radiation Equipment – Minor Maintenance Records related to the minor maintenance, daily function checks, routine and package surveys, and instrument calibration performed in accordance with the manufacturer's instructions on a Facility’s testing equipment.

E WAC 246-225-130 (2) (u) (ii) (F)

Radiation Monitoring Records – Human Exposure Records related to the monitoring of annual doses received by individuals, the doses received during planned special exposures, accidents, and emergency conditions. Includes adults and minors who receive in excess of their limitations in a single year and individuals entering a high or very high radiation area. May include surveys of radiation for determining an individual’s dose from external sources.

A RCW 70.98.100

Radiation Monitoring Records – Radioactive Materials Records documenting the results of calibrations for packages received that contain radioactive materials. Includes the date and time a package was received, the time and date of calibration, the results and levels of the test, the name of the person who performed the test.

E WAC 246-225-130 (2) (u) (ii) (F)

Radiation Protection Program Records documenting the prevention of unnecessary radiological exposure to humans and the environment.

E

WAC 246-239-020 Repealed; WAC 246-240-015 Repealed

Radiation Protection Program – Audits Records related to the audits or reviews on the Radiation Protection Program.

E WAC 246-240-015 (3) (c) Repealed

Radioisotopes Records related to the receipt, transfer, use, storage, delivery, disposal, and overexposure of radioisotopes.

A RCW 70.98.100; 10 CFR 30.51

Radiology Surveys Records related to surveys to evaluate radiation levels, concentrations or quantities of radioactive materials, and potential radioactive hazards that could be present. Includes surveys of physical radiation for the purpose of determining whether each sealed source is in its shielded position prior to securing the radiographic device, storage container, or source changes in a storage area. The entire device is surveyed including the source guide tube.

E

WAC 246-239-070 (2) Repealed; WAC 246-225-130 (2) (u) (ii) (F)





Radiology Utilization Logs Logs documenting each source of radiation, the make and model number, storage container, identity of the radiographer, location, and date of its use.

E

Requests for Tests Includes oral, written, and electronic requests for tests.

E

42 CFR 493.1105

Sealed Radiation Sources – Inventory Records related to staff conducting physical inventories to account for all sealed radiation sources received or possessed under an appropriate license.

E WAC 246-235-080; WAC 246-239-080 Repealed

Test Procedures Copies of each test procedure with the date of its initial use. May include the test methodology and results, who performed the test, possible side effects, and any necessary equipment.

E

Test Procedures – Discontinued Records of each test procedure with the dates of its initial use and discontinuance. May include the test methodology and results, who performed the test, possible side effects, and any necessary equipment.

E

Test Procedures – Errors Records include original and corrected reports.

E 42 CFR 493.1219(d)(3)

Testing – Sealed Sources Records related to the testing of sealed sources of radiation by radiology for leaks or contamination.


Testing – Unsealed Sources Records related to the testing of unsealed sources of radiation by radiology for leaks or contamination.


Testing Entry Control Devices Records related to the testing of the entry control devices to secured areas housing high levels of radiation. Includes date, time and results of each test.

E

Therapeutic X-Ray Systems of less than 1MeV Records of the calibrations of the therapy system.

E WAC 246-225-120 (2) (e) (vi)

Therapeutic X-Ray Systems of more than 1MeV Records of the calibrations of the therapy system and of the dosimetry system.

E WAC 246-225-130 (2) (u) (ii) (F)

Ultrasound G Video records of diagnostic tests (e.g., arthroscopies) Retain only those portions, which are specifically selected by the physician to accompany the report in the patient’s medical record.

F G

X-ray films X-ray films are considered part of the medical record and must be retained for time prescribed for retention of medical records.

F G

X-Ray Logs X-ray logs include name of patient, type of examination, date of the exam, and technician performing the service.

D

1.1.1.10. Laboratory, Therapy and Imaging






Autoclave/Sterile Supply Records Records related to autoclave/sterile supply.

D

Blood and blood-product testing records Records must be kept at least 5 years after processing or 6 months after the latest expiration date for the individual product, whichever is later.

F G

21 C.F.R. §606.160 and 42 C.F.R. §493.1107*

Blood Bank – ABO and RH Types Records related to type testing of blood.

D 21 CFR 606.160

Blood Bank – Adverse Reactions to Transfusions Records related to adverse reactions to blood transfusions.

D 21 CFR 606.160

Blood Bank – Blood Donor Records Records related to blood donors including histories, examinations, consent, reactions, donor selection, results of required tests performed on plasmpheresis and cytopheresis donors, A and temporary deferrals, investigation and follow-up, therapeutic bleedings, immunization, and blood collection.

D 21 CFR 606.160

Blood Bank – Blood Test Results Records related to blood test results including interpretations and release data for compatibility testing.

D 21 CFR 606.160

Blood Bank – Final Disposition of Blood and Components Records related to the final disposition of blood and blood components.

D 21 CFR 606.160

Blood Bank – General Records Records related to information concerning sterilization of supplies and reagents, responsible personnel, errors and accidents, maintenance of equipment and the physical plant, expiration dates of supplies and reagents, and logs which indicate on-hand inventory and notices of emergency shortages.

D 21 CFR 606.160

Blood Bank – Quality Control Records related to the calibration and standardization of equipment, performance checks, periodic check of sterile technique, and periodic tests of the capacity of shipping containers to maintain the proper temperature.

D 21 CFR 606.160

Blood Bank – Refrigeration and Blood Inspection Records

D 21 CFR 606.160

Blood Bank – Transfusion Request Records Transfusion requests received by the blood bank.

D 21 CFR 606.160

Blood donor histories and pertinent records Records must be kept at least 5 years after processing or 6 months after the latest expiration date for the individual product, whichever is later

F G

21 C.F.R. §606.160

Blood transfusion records Records must be kept at least 5 years.

F G

42 C.F.R. §493.1107 *

Bone Marrow Test Reports Records related to the testing of bone marrow.

F G

RCW 70.41.190

Cytology reports Must be kept at least 10 years.

D Refer to 3.3 for Patient Specific Cytology Reports

Cytology slides and cell blocks Must be kept at least 5 years E

Refer to 3.3 for Patient Specific





Cytology Reports Electrocardiogram Tracings Patient electrocardiogram tracings.

F G

Electroencephalogram Tracings Patient electroencephalogram tracings.

F G

Final Test Reports – Pathology/Histology/Cytology Laboratory copies of test results and preliminary reports specific to pathology, histology and cytology. Includes histology and pathology specimen logs and slides.

D 42 CFR 493.1109*; 42 CFR 493.1257*

Histopathology Stained slides must be kept at least 10 years; specimen blocks at least 2 years from date of examination.

D 42 C.F.R. §493.1259(b)*

HIV Test Results Records consist of anonymous test results for HIV.

E

42 CFR 493.1109*

HIV Test Results Records consist of seropositive and seronegative confidential test results for HIV.

F G

RCW 70.41.190

Immunohematology reports Reports must be kept at least 5 years.

D 42 C.F.R. §493.1109*

Quality Control Records Records related to the quality control of laboratory sample processing and testing to assure that the samples were tested in the same exact manner as the regular patient samples.

E

42 CFR 493.1221 This deals with Cytology.

Reports – Complete Reports documenting each step in the processing, testing, and reporting of patient specimens to assure the accuracy of the testing.

E 42 CFR 493.1109*

Test Requisitions Requisitions authorizing a laboratory to perform tests on a sample.

E 42 CFR 493.1105

Pathology reports and slides Retain unusual case reports permanently. Reports must be kept at least 10 years.

F G

42 C.F.R. §493.1109*

Patient testing records (including, if applicable, instrument printouts) Reports must be kept at least 2 years.

D 42 C.F.R. §493.1107*

Patient Testing Reports – Immunohematology/Histocompatibility Immunohematology and histocompatibility specific reports related to the processing, testing, and reporting of patient specimens to assure the accuracy of the testing.

E 42 CFR 493.1109*

Patient Testing Reports – Laboratory Copies Reports documenting each step in the processing, testing, and reporting of patient specimens to assure the accuracy of testing, and the loan or referral of slides to another laboratory.

E 42 CFR 493.1101

Procedure manuals; method validation Must be kept at least 2 years.

D

Quality control reports

D 42 C.F.R. §493.1221(a)





Registers of tests – logbooks (chronological)

D


E 42 CFR 493.1105

Radioisotopes Records related to the receipt, transfer, use, storage, delivery, disposal, and overexposure of radioisotopes.

A 10 CFR 30.51

Screening Procedures Records relating to screening procedures for health risk appraisal, blood pressure, blood pressure referral, vision, hearing and speech, diabetics screening, syphilis serology, gonorrhea, and other laboratory screenings and tests.

F G

RCW 70.41.190

Screenings for Infant Genetic or Metabolic Disorders-Copies Copies of test results for infant genetic or metabolic disorders. Originals are maintained in the patient’s medical record.

H

WAC 246-650-020; RCW 70.41.190

Screenings for Infant Genetic or Metabolic Disorders-Originals Original test results for infant genetic or metabolic disorders. Originals are maintained in the patient’s medical record.

G

WAC 246-650-020; RCW 70.41.190

Specimen records Must be kept at least 2 years.

D

Sterilizers/ Bacteriological Tests Records related to sterilizers and monthly bacteriological tests. Includes recording charts, chemical indicators, Bonne-Dick tests, readings from jacket pressure gauge, and chamber pressure gauge.

E


E


E


E 42 CFR 493.1219(d)(3)

Test results not otherwise specifically mentioned Reports must be kept at least 2 years. D

42 C.F.R. §493.1109*

Tissue Tracking System Records Records related to the receipt and disposition of all organs and tissues transplanted within the hospital.

A

Video Tapes of Diagnostic Tests Videotapes created for other diagnostic tests not listed elsewhere.

E

Therapy Treatment Records Records related to therapy treatment that are not duplicated in the patient health records.

D

1.1.1.11. Nuclear Medicine






Calibration records

D

Disposition of radiopharmaceuticals

D

Exposure records A

42 C.F.R. §482.54, HCFA Conditions of Participation

Film body records

D

Radiation dose records A

Refer to 1.1.1.9 – Radiation in Imaging.

Reports of overexposure

A 10 C.F.R. §30.51

Utilization records

D

1.1.1.12. Nursing


Chart Audits Internal audits and related work-papers performed on patient charts.

E

Delivery Room Logs Logs detailing the names of who utilized the delivery room and when. Includes cross-references with a patient identification number for tracking or billing purposes.

D

Education and Training Records Records related to nurses training and certification.

E

Implant Logs Implant logs listing items implanted into patients during surgical procedures.

D

Intensive Care Unit Logs Log created and maintained by the Intensive Care Unit of a facility.

D

Nursing and Patient Care Practices

Current + D

Nursing Care Manuals Documentation manuals detailing nursing care procedures.

D

Nursing Care Plans Records related to daily care provided by nurses.

F G

Private Duty Name Files

After Last Use--D

Reference Cards Includes duplicate copies of nursing reference notes.

H

Special Procedures Unit Logs Records related to endoscopies and outpatient surgeries. Includes patient arrival and departure time and is documented in the patient’s health file.

E





Staffing Records Daily, weekly, monthly, bimonthly work schedules, and assignment sheets for medical personnel. Includes nursing staff, medical aides, and support staff who provide medical treatment including phlebotomists; includes methodology used.

B

24 CFR 585.401

Visit Notes Records consist of observations and notes concerning patients, which do not become part of the patient medical record.

E

1.1.1.13. Nutrition Services


Bacteriological testing of ice

E

Dietary Recipe Records Standardized dietary recipe records used in the preparation of patient meals by the kitchen staff. Includes a nutritional analysis, ingredients list, and serving size notation.

E WAC 246-320- 305

Dietary Records Inservice Training Records; Bacteriological Testing of Ice; Meal Counts

E

Dietetic Service Personnel, Number of Regulations require general acute-care hospitals and acute psychiatric hospitals to maintain records listing the number of dietetic service workers and their job titles and hours worked, but do not specify retention periods.

E

Dietician Counseling Summaries Annual summaries provided by a nutritionist or dietitian that evaluate the menus, sanitation, policies and procedures, and recommend modifications for the food preparation and service.

E WAC 246-320-305

Food Costs Records related to the purchase and cost of food and food services.

D

Food purchased Regulations require general acute-care hospitals, acute psychiatric hospitals, skilled nursing facilities and intermediate care facilities to maintain records of food purchased for 1 year.

E

Inspection Reports

E WAC 246-215-230 Repealed

Menus Records related to food service: include menus, food lists, name of dietitian, date, average portion size, schedule of time, and length of food service.

E WAC 246-320-305

1.1.1.14. Pharmaceutical


Alcohol (Tax Free) Inventory

E 27 CFR 22.164*

Controlled Substances – Dispensed or Administered Providers must keep for at least 2 years daily records showing the kind and quantity of narcotics dispensed or administered, the names and addresses of persons to whom narcotics were dispensed or administered, and the names and addresses of persons upon whose authority, and the purpose for which narcotics were dispensed or administered.

E

WAC 246-873-080 (7) (i); RCW 18.64.470; 21 CFR 1304.04; 21 CFR 1304.22





Controlled Substances – Inventory and Orders Records related to the identification and treatment of required inventories and logs pertaining to drugs held by facilities, including pharmacists and EMS units. Includes narcotics.

E

RCW 18.64.470; WAC 246-873-080 (7) (i); 21 CFR 1304.04 (a

Inspection reports by pharmacist of emergency drug supplies General acute-care hospitals and acute psychiatric hospitals must keep records of inspections for at least 3 years.

E RCW 69.41.042; RCW 69.41.270 Repealed

Methadone Records Records related to the inventory and administration of methadone. Must be kept 3 years from date of dispensing.

E 21 CFR 310.505*; 21 CFR 291.505(d)(13)(ii)*

Narcotics inventory Must be kept at least 2 years.

E 21 C.F.R. §1304.04(a)

Patient Profiles Records related to patient profiles maintained by pharmacies. Includes records to whom new and/or refill prescriptions are dispensed.

E

Pharmacy Register

E WAC 246-873-080 (7) (i )

Prescriptions Records related to written prescriptions maintained by pharmacies. Keep prescriptions for certain controlled substances in a separate file. Must be kept at least 2 years

E RCW 18.64.245; 21 CFR 1304.04(h)

Radioactive Drugs Includes inventory and orders of radioactive drugs.

E WAC 246-903-020

Recall Records

E WAC 246-873-080 (8)

1.1.1.15. Purchasing & Receiving


Packing slips

E

Purchase orders Keep copy of record on voucher in business office.

E

Purchase requisitions

E

Receiving reports

E

Returned goods credits

E

1.1.1.16. Quality Improvement


Administrative Files Administrative records for individual facility records.

E





Immunohematology – Quality Control Records Records related to the quality control of immunohematology sample processing and testing to assure that the samples were tested in the same exact manner as the regular patient samples.

E 21 CFR 606.160; 42 CFR 493.1221

Infection Control Program Records Records include surgical infection investigation reports, training course content and the review and evaluation of all septic isolation, and sanitation techniques used in the medical facility. Includes reports on employees who may have been exposed to a communicable disease, their work restrictions, and estimated date of reinstatement.

E WAC 246-320-265

Inventory and Orders Includes records of inventories of supplies ordered, maintained, and used by individual departments. For controlled substances see WA-MED-80-02.

E

QC Reports –Quality Control Reports Quality control reports for individual facility departments.

D .

Respiratory Protection Program Records related to Respiratory Protection Programs.

E

Training and Education Records Records related to training and certification of employees, which does not include radiological, diagnostic imaging, nuclear medicine training, or nursing.

E

1.1.1.17 Security


Air Sampling and Bioassays Records related to the results of air sampling, bioassays, and surveys conducted in the radiology section which are sufficient enough to identify potential hazards, permit proper equipment selection, estimate exposure levels, and to evaluate actual intake levels.

D

Badge Lists Lists detailing information about employees and visitors who have been issued security badges.

E

Courier Authorizations Authorizations to courier services to transport sensitive information.

E

Employee Clearance Lists Lists identifying employees and visitors issued special security clearances.

E

Incident Reports Reports of unusual incidents that are recorded by a witness to the incident in a formal manner such as a log, event book, incident form, etc. May be used to report security or injury incidents or to note disturbances in the work place such as fire alarms, roof leak, computer and power outages, car alarms, and other events.

B

Motor Vehicle Maintenance Records documenting the maintenance performed on motor vehicles.

E

Risk Management Reports Records related to internal risk management. Includes education and training for non-physician employees, analysis of patient grievances, review of incident reports, and minutes of the risk management committee.

D





Safety Inspections Records documenting the inspection of facilities for potential safety hazards.

E

Safety Investigations Records documenting investigations performed after accidents or injuries.

E

Safety Programs Records documenting company safety programs.

D Legal Liability

Security Disturbances Records detailing investigations of events where security was compromised. E

Security Guard Files Records related to the hiring and use of security guards.

E

Security Plans Records documenting the procedures pertaining to security of employees, equipment, buildings, and information.

D Legal Liability

Visitor Registration Logs Lists of visitors entering organization premises.

E

1.1.1.18 Therapy



E 42 CFR 493.1105


E


E


E 42 CFR 493.1219(d)(3)

Therapy Treatment Records Records related to therapy treatments that are not duplicated in the patient health records. May include occupational, physical, speech, and inhalation therapy.

F G

RCW 70.41.190

1.2 Operations


Accreditation surveys and reports Records related to accreditation surveys and results. Includes inspection reports by accrediting institutions, notices of corrections, correction reports, activity calendars, in-house surveys and testing done prior to the actual accreditation survey

D RCW 70.41.030; WAC 246-320-025

Medical directives, policy and procedure manuals Directives, policies, and procedures for facility operations includes emergency code procedures and

D





cards Transfer patients: medical and “other” records related to patient transfers to or from the hospital Federal law requires maintenance of records for 5 years from date of transfer.

D 42 U.S.C. 1395cc(a)(1)(ii)

Policy and procedures manuals – departmental

B

Policy and procedures manuals – other departments

H

1.3 Organization


Policy Statements Records documenting the policies to be followed by the organization.

A

Procedure Manuals Documentation manuals detailing procedures that implement the policies of the organization.

A

1.4 Compliance

1.4.1 Audits


Audits – External Records reviewing and documenting ethics and compliance activities created as part of an audit conducted by an individual or group outside the organization. Includes executive summaries, audit reports, plans of corrective action, and audit work papers.

D

Audits – Internal Copies of records reviewing and documenting ethics and compliance activities created as part of an audit conducted by an individual or group within the organization. Includes executive summaries, audit reports, plans of corrective action, and audit work papers.

D

1.4.2 Ethics


Corporate Ethics and Compliance Policy Committee Minutes Includes meeting minutes, agendas, and supporting documentation.

A

Correspondence with Ethics and Compliance Officers Files containing copies of letters and memoranda sent to Ethics and Compliance Officers and original letters and memoranda received from Ethics and Compliance Officers.

E

Correspondence with OIG Files containing copies-reports, letters and memoranda sent to the Office of the Inspector General and original letters and memoranda received from the Office of the Inspector General.

B





Ethics and Compliance Committee Minutes Includes meeting minutes, agendas, and supporting documentation.

A

Ethics and Compliance Officer (ECO) Designation Forms Forms designating facility Ethics and Compliance Officers.

E

Ethics, Compliance and Corporate Responsibility Committee of the Board of Directors Meeting Minutes Includes meeting minutes, agendas, and supporting documentation.

A

General Correspondence Files containing copies of letters and memoranda sent to others and original letters and memoranda received from external sources/parties.

E

Investigation Documentation Records related to ethics and compliance investigations into alleged violations including Ethics Line complaints. Includes investigation workpapers, support and background documents, and final reports.

D

Newsletters Newsletters produced by the Ethics, Compliance & Corporate Responsibility Department.

D

Policies Official company policies adopted by the Corporate Ethics and Compliance Policy Committee.

A

Policy Drafts and Work papers Drafts and work papers used in the creation of policies adopted by the Corporate Ethics and Compliance Policy Committee.

H

Quarterly Reports Quarterly reports from Facility Ethics and Compliance Officers.

D

Responsible Executive Program Includes Responsible Executive Program description and list of Responsible Executives.

E

Speeches Copies of speeches given by Ethics, Compliance and Corporate Responsibility Department employees.

E

Training Materials Includes manuals, videotapes, guidebooks, and supporting materials to train employees on ethics and compliance matters.

D

Training Programs Records related to the development and operation of ethics and compliance related training programs and seminars.

E

1.4.3 Reports

1.5 Human Resources


Affirmative action programs

C 29 C.F.R. §1627.3

Benefit beneficiary designations A





Criminal records of employees

E – after termination

EEO-1

Current + E 29 C.F.R. §1602.7

Employee health (medical records) Employees subject to OSHA regulations Federal and California OSHA regulations require, in essence, that medical records be retained for the duration of employment plus 30 years for all employees who are exposed, or potentially exposed, to hazardous substances, including blood borne pathogens, or to a hazardous environment.

Hazardous substances include those listed in the latest edition of the Registry of Toxic Effects of the National Institute for Occupational Safety & Health. Hazardous environments include noise, heat, cold, vibration, repetitive motion, ionizing and non-ionizing radiation, and hypo- and hyperbaric pressure.

A

Employee health (medical) records – Employees not subject to OSHA regulations Six years represents the outside statute of limitations period for most employer-employee related claims and grievances. California regulations require all health facilities, clinics and home health agencies to keep these records for a minimum of 3 years after termination of employment.

D

Employment contracts – executive and management

Current + D 42 C.F.R. §413.20

Employment contracts – physicians/healthcare providers

Current + D 42 C.F.R. §413.20

Employee manual Official records establishing business practices for personnel actions.

D

Employment retirement benefit records (e.g., ERISA reports, correspondence and miscellaneous information necessary for determination of benefits)

Date of participant’s death, or termination

of payment obligation + D

29 U.S.C. §1027

Equal Pay Act records

E 29 C.F.R. §516.6

ERISA required disclosures and benefit plans Includes back-up to provide in sufficient detail the necessary basic information and data from which the documents may be verified, explained, or clarified and checked for accuracy and completeness.

D 29 U.S.C. §1027

FMLA Payroll and employment data, dates of leave, hours of leave, employment practices, premium payment records of dispute, written notices

E FMLA §825.500

FMLA leave requests

E FMLA §106

Garnishment records

D

Hazardous waste and use of pesticides training records Persons handling hazardous waste and use of pesticides must have specified training and records must be kept for 3 years after separation from job.

E--after separation from job





Job classifications D

Job descriptions Current + C 29 C.F.R. §1602.14

Labor Management Collective Bargaining Agreements Includes related documents; certificates; notices; memoranda; and related written agreements

E—from last effective date

29 C.F.R. §516.5

Labor Management Reporting Records

D—after filing report

Loan programs for nursing students

E 42 C.F.R. §57.215

OSHA logs and summaries; OSHA forms 102/102A

E 29 C.F.R. §1904.6

OSHA requirements – form 101 log Supplemental record for each injury – not needed if Workers Comp record is used

E 29 C.F.R. §1904.6

OSHA requirements – form 200 log Recordable occupational injuries and illness

E 29 C.F.R. §1904.6

OSHA requirements – injury and illness survey

E 29 C.F.R. §1904.6

Overtime reports

E

Payroll records Includes hours worked; leaves of absence; overtime, vacation and sick leave entries; time cards; and wages paid

Retention of comprehensive payroll records is required under numerous federal and state laws, including the Fair Labor Standards Act, Equal Pay Act, Age Discrimination in Employment Act, Title VII of the Civil Rights Act, Americans with Disabilities Act, California Fair Employment & Housing Act, California Unemployment Insurance Code and ERISA. Although most of the act requires retention for a period no longer than 4 years, ERISA requires current availability of all payroll records necessary to determine entitlement to pension benefits. It is therefore recommended that payroll records be permanently retained (as ERISA requirements vary according to the type of pension plan, facilities may wish to have their attorneys review their plans to determine whether a shorter retention period may be appropriate and to determine which payroll records should be retained).

A Refer to 2.1.6 – Payroll.

Pension annual reports, plan descriptions, summary plan descriptions, modifications and changes

E 29 C.F.R. Part 486

Personnel policies and employee handbooks

Current + E 29 C.F.R. §1602.14

Personnel records for employees and applicants required by Title VII of the Civil Rights Act, the Americans with Disabilities Act and the Age Discrimination in Employment Act Providers must keep for at least 1 year application forms submitted by applicants, requests for reasonable accommodations, and other records relating to hiring, promotions, demotions, transfers, lay-offs or terminations, rates of pay or other terms of compensation, and selection for training or apprenticeship.

E—after date of

employment action

29 C.F.R. §§1602.14 and 1627.3

Applications – employees, permanent and temporary, and non-employees Records must be kept at least 1 year. Longer in cases of interest. E

29 C.F.R. §§1602.14, 1602.20, 1602.21





and 1627.3(b). See 1.5.9.

Applications for job openings and advertised postings

E 29 C.F.R. §1602.21

Applications, resumes and other pre-employment information for non-hires

E 29 C.F.R. §1602.14

Requests for reasonable accommodations

E

Applications – employees, permanent and temporary, and non-employees Records must be kept at least 1 year. Longer in cases of interest.

E

29 C.F.R. §§1602.14, 1602.20, 1602.21 and 1627.3(b). See 1.5.9.

Applications for job openings and advertised postings

E 29 C.F.R. §1602.21

Applications, resumes and other pre-employment information for non-hires

E 29 C.F.R. §1602.14

1.5.1.17 Benefits


Actuarial Records Reports projecting life expectancy, future benefits, and other information needed to calculate contributions and provisions of benefit programs.

D 29 CFR 1627.3; 29 USC 1027

Beneficiary Designations Documentation designating the person to whom employee benefits will be paid in the event of the death of the employee.

D 29 CFR 1627.3; 29 USC 1027

Educational Assistance Financing Records regarding educational assistance provided to plan participants.

D 29 CFR 2610.11; 29 USC 1113

Employee Assistance Counseling Records Records detailing employee benefits received through the employee assistance program.

D 29 CFR 2610.11; 29 USC 1113

Employee Relocation Records Records indicating relocation benefits provided to eligible employees.

D 29 CFR 2610.11; 29 USC 1113

Employee Stock Option Records Records regarding stock options received by employees including option exercises, summary reports, and work papers.

D 29 CFR 2610.11; 29 USC 1113

Employee Stock Purchase Plan Records Records detailing transactions in the employee stock purchase plan including statements, summary reports, enrollments, and work papers.

D 29 CFR 2610.11; 29 USC 1113

Flexible Spending Accounts - Records/Claims Records regarding employee flexible spending accounts including contributions, claims, account activity reports, enrollments, claims reports, and work papers.

D 29 CFR 2610.11; 29 USC 1113

Group Life Insurance Records Records documenting benefits received under group life insurance plans including claims, summary reports, correspondence, and work papers.

D 29 CFR 2610.11; 29 USC 1113





Health Insurance Claims Records documenting employee claims and benefits received under the health insurance program including correspondence, summary claim reports, and work papers.

D 29 CFR 2610.11; 29 USC 1113

Incentive Plan Records Records regarding benefits received by employees through the incentive plan including summary reports and work papers.

D 29 CFR 2610.11; 29 USC 1113

Paid Time Off Records Records documenting employee paid time off accrued and used.

D 29 CFR 2610.11; 29 USC 1113

Pension/401(k) Retirement Plan Vesting Files Records documenting employees who have vested under the pension plans, and are eligible for payments under the plan.

C 29 USC 1059

Profit Sharing Records Records regarding benefits received under a profit sharing plan including correspondence, summary reports, statements, and work papers.

D 29 CFR 2610.11; 29 USC 1113

1.5.2 Benefit Plans/Programs


401(k) Retirement Plan Records detailing employee eligibility and benefits under company 401(k) retirement plan.

D 29 CFR 1627.3; 29 USC 1027

401(k) Retirement Records Records regarding employee 401(k) retirement accounts including enrollments, contributions, summary reports, statements, correspondence, and work papers.

D 29 CFR 2610.11; 29 USC 1113

Disability Plan Records detailing employee eligibility and benefits under the disability insurance plan.

D 29 CFR 1627.3; 29 USC 1027

Education Assistance Plan Records detailing employee eligibility and benefits under the education assistance program.

D 29 CFR 1627.3; 29 USC 1027

Employee Paid Time Off Plan Records detailing employee eligibility and benefits under employee paid time off plan.

D 29 CFR 1627.3; 29 USC 1027

Employee Relocation Program Records detailing employee eligibility and benefits under the employee relocation program.

D 29 CFR 1627.3; 29 USC 1027

Employee Stock Option Program Records detailing employee eligibility and benefits under the employee stock option program.

D 29 CFR 1627.3; 29 USC 1027

Employee Stock Purchase Plan Records detailing employee eligibility and benefits under the employee stock purchase plan.

D 29 CFR 1627.3; 29 USC 1027

Flexible Spending Account Plans Records detailing employee eligibility and benefits under flexible spending account plans.

D 29 CFR 1627.3; 29 USC 1027

Group Life Insurance Plans Records detailing employee eligibility and benefits under company group life insurance plans.

D 29 CFR 1627.3; 29 USC 1027





Health Insurance Plans Records detailing employee eligibility and benefits under company health insurance plans.

D 29 CFR 1627.3; 29 USC 1027

Incentive Plans Records detailing employee eligibility and benefits under company incentive plans.

D 29 CFR 1627.3; 29 USC 1027

Pension Plans and Amendments Records detailing employee eligibility and benefits under company pension plans.

A 29 CFR 1627.3; 29 USC 1027

Pension committee minutes

A

Pension eligibility and records of employee service

A

Pension plan determination letters

A

Pension records

A

Profit Sharing Plans Records detailing employee eligibility and benefits under company profit sharing plans.

D 29 CFR 1627.3; 19 USC 1027

1.5.3 Collective Bargain Agreements

1.5.4 Government Reporting


Benefit Reports Legally required reports related to employee benefits and benefit plans.

D 29 CFR 30.8(E)

Birth certificates

A

Birth records to local government Records consist of copies of vital birth records and certificates filed with state registrar of vital statistics.

A RCW 70.58.070

Birth room record

A

Communicable disease reports to state and local health departments

E WAC 246-100-021; RCW 70.58.270

Death certificates

A

Death Records Records that track the transfer of corpses from the hospital to outside locations.

E

Death Records Records that track the transfer of corpses from the hospital to outside locations.

Death records to local government Copies of death records required by local government

A RCW 70.58.160

Equal Employment Opportunity Forms Copies of legally required forms submitted to the EEOC documenting hiring and personnel actions.

D 29 CFR 30.8(E)

Psychiatric reports to state health department

D





Quarterly Reports to government agencies

E WAC 246-454-070

Salary Administration Legally required forms submitted to the government to report earnings, deductions, taxes, etc.

D 29 CFR 30.8(E)

Venereal disease and other public health reports

E

Venereal disease and other public health reports

1.5.5 Health and Safety


Accident/Injury Reports Records describing job-related accidents and injuries.

D 29 CFR 1904.6

Damage Reports Records documenting damage to equipment or property.

D 29 CFR 1904.6

Employee Hazardous Exposure Records Records documenting specific instances when employees were exposed to hazardous substances.

A 29 CFR 910.1020; 29 CFR 1910.1001

Employee Medical Records - Hazardous Exposure Employee medical records related to hazardous exposure.

A 29 CFR 910.1020; 29 CFR 1910.1001

Employee Medical Records - Non Hazardous Exposure Employee medical records not related to hazardous exposure.

D 29 CFR 1904.6

Hazard Communications Records The communication of information about hazardous substances or dangerous situations to employees.

A 29 CFR 910.1020; 29 CFR 1910.1001

Material Safety Data Sheets Records maintained in locations where hazardous substances exist that describe the substances, effects, safety precautions, antidotes, and other related information.

A

40 CFR 68.200; 40 CFR 68.39; 40 CFR 68.67; 42 USC 9612; 29 CFR 1926.59

Radiation Exposure Records Records documenting the level and type of radiation to which employees have been exposed.

A 29 CFR 910.1020; 29 CFR 1910.1001

Worker’s Compensation Records Records documenting occupational injuries and claims involving worker’s compensation.

D

1.5.6 Personnel Administration


Employee Grievances Records related to employee grievances filed with human resources.

D

Layoff Records Records related to corporate labor force reductions.

D 29 CFR 1620.33; 29 CFR 1602.14; 29 CFR 1627.2, .3





Promotion Records Records related to employee promotions.

D 29 CFR 1620.33; 29 CFR 1602.14; 29 CFR 1627.2, .3

Retirement Records Records related to decisions to retire employees.

D 9 CFR 1620.33; 29 CFR 1602.14; 29 CFR 1627.2, .3

Transfer Records Records related to decisions to transfer employees.

D 29 CFR 1620.33; 29 CFR 1602.14; 29 CFR 1627.2, .3

1.5.7 Salary Administration


Bonus Determinations Records related to decisions to issue bonuses.

D 29 CFR 1620.33; 29 CFR 1602.14; 29 CFR 1627.2, .3

Cost of Living Records Reference materials available to assist in decisions to determine changes in the cost of living.

D 29 CFR 1627.3

Direct Deposit Application and Authorization Records related to employee authorized payroll direct deposit.

E

Earnings Records Records summarizing earnings of individual employees.

D 29 CFR 1627.3

Form 1099 Internal Revenue Service Form 1099 for contract workers.

D 26 CFR 301.6501(E)-1

Form 940/941 Internal Revenue Service Form 940 & 941.

D 26 CFR 301.6501(E)-1

Form W-2 Internal Revenue Service Form W-2’s for company employees.

D 26 CFR 301.6501(E)-1

Form W-4 Internal Revenue Service Form W-4 for company employees.

D 26 CFR 301.6501(E)-1

Form W-9 Letters W-9 letters sent to company employees.

D 26 CFR 301.6501(E)-1

Pay Scales Charts used to determine salary for job classifications.

D 29 CFR 1627.3

Payroll Deduction Authorizations Records related to employee authorized payroll deductions.

D 26 CFR 301.6501(E)-1

Salary Surveys Information gathered to determine industry and geographic salary guidelines for job classification.

D 29 CFR 1627.3

Wage rates, salary schedules, seniority systems

E

29 C.F.R. §§1627.3, 516.2-6(FLSA) and 516.11-29





Wage statements, Itemized

Must be kept at least 3 years.

1.5.8 Personnel Files


Active Employee Personnel Files Records documenting detailed personnel actions for active employees including personnel action forms, education records, evaluations, and salary records.

D 29 CFR 1620.33; 29 CFR 1602.14; 29 CFR 1627.2, .3

Employee Evaluations Completed employee performance evaluation forms.

D 29 CFR 1620.33; 29 CFR 1602.14; 29 CFR 1627.2, .3

Personnel Action Request Forms (PAR) Forms used by Human Resources and Payroll to create or change information regarding an employee’s position, salary grade, payroll records, and termination.

D 29 CFR 1620.33; 29 CFR 1602.14; 29 CFR 1627.2, .3

Temporary Employee Personnel Files Records documenting personnel actions for temporary employees.

D 29 CFR 1620.33; 29 CFR 1602.14; 29 CFR 1627.2, .3

Terminated Employee Personnel Files Records documenting detailed personnel actions for terminated employees.

D 29 CFR 1620.33; 29 CFR 1602.14; 29 CFR 1627.2, .3

Terminated Employee Personnel Files - Department Copy Department copy of personnel files for terminated employees.

Transfer to HR

1.5.9 Personnel Selection


Applications - Rejected Records documenting hiring activities for employees who were not hired.

E 29 CFR 1627.3

Applications – employees, permanent and temporary, and non-employees Records must be kept at least 1 year. Longer in cases of interest. E

29 C.F.R. §§1602.14, 1602.20, 1602.21 and 1627.3(b).

Applications for job opening and advertised postings

E 29 CFR 1602.14

Applications, Resumes and other pre-employment information for non-hires E 29 CFR 1602.14

Employment Requisition Files Records related to the requisition of new employees.

E 29 CFR 1627.3

Job Announcements Records documenting notices of job openings communicated in the media or other means.

E 29 CFR 1627.3

Verification of Employment Eligibility (INS Form I-9) INS Form I-9 required by federal government.

Keep In Personnel File

8 CFR 274A.2

1.5.10 Training





Course Listings Listing of training opportunities available to employees.

H

Employee Certification Certification or licenses required for employees to perform a particular job or task.

Keep In Personnel File

24 CFR 585.401

Training Materials Records containing materials used to train employees.

E 24 CFR 585.401

Training Programs Records related to the development and operation of company sponsored training programs and seminar.

E 24 CFR 585.401

1.6 Information Services


Access Security Records Records created for security purposes to control or monitor individual access to a system and its data, including but not limited to, user account records, security login information, and password files.

Retained for Full Retention of Master Files; See INS-10-08

Audit Trail Records Files needed for electronic data audits such as files or reports showing transactions accepted, rejected, suspended, and/or processed; history files/tapes; records of on-line updates to application files or security logs.

D

Batch Data Entry Control Records Forms and logs used to reconcile batches submitted for processing against batches received and processed.

E

Computer Job Schedules and Reports Schedules or similar records showing computer jobs to be run and other reports by computer operators or programmers of work performed.

E


E

29 C.F.R. §§1627.3, 516.2-6(FLSA) and 516.11-29 Maybe move to 1.5.7 Salary Administration

Wage statements, itemized Must be kept at least 3 years. E

Maybe move to 1.5.7 Salary Administration

Computer programs – non-accounting related

Retain enough documentation to support or permit reconstruction of programs which produce reports with specified retention

periods

Data Processing Planning Records Reports, studies, analyses, projections, and similar records concerning the creation, development, or modification of data processing systems and services except for disaster recovery plans.

E





Data Processing Policies and Procedures Records of data processing policies and procedures including those covering access and security, systems development, data retention and disposition, and data ownership. Records of procedures include but are not limited to, data entry, operation of computer equipment, production control, system backup, and compliance with electronic records rules.

B

Data produced from on-line terminals or mini-computer systems (branch system)

If on-line interactive terminals or remote mini-computer systems with various output devices are used to produce records, it is up

to the user to establish retention times for saved or stored data if the data is used in the conduct of business on a continuing basis,

consistent with this retention schedule.

Disaster Preparedness and Recovery Plans Records related to the protection and re-establishment of data processing services and equipment in case of a disaster.

E

Electronic Calendar Documentation of personal schedules and appointments that is maintained electronically (e.g., in an Outlook calendar, Schedule+, GroupWise calendar, Calendar Creator+, etc.)

H

Electronic Mail - Deleted Messages Messages that have been deleted by users from their mailboxes and placed by the system in a special repository for deleted messages (e.g., Deleted Items Folder, Trash Folder, Wastebasket Folder, etc.). The E-mail System Administrator is responsible for retention of deleted messages.

CY + 1 year online or on appropriate electronic backup medium

Electronic Mail - Record The originator of each message must determine if the message constitutes a business or medical record and ensure appropriate retention in either hard-copy or electronic form. The originator is the sender of an internal message or the recipient of an electronic message from an external source.

Retain business or medical record in accordance with appropriate textual record retention series. Users may delete non-record

messages.

Electronic Mail - Transitory Messages Messages informal in nature and have short-lived or no administrative value. (See ADM-90-18)

Users may delete transitory message(s) after the message value

is achieved.

Electronic Media Library System Files Records used to control the location, maintenance and disposition of media in an electronic media library except for records destruction documentation.

Until Related Records or Media are Destroyed or Withdrawn

Finding Aids, Indexes, and Tracking Systems Automated indexes, lists, registers, and other finding aids used to provide access to the hard copy and electronic records.

Maintain for Length of Retention for the Hard Copy or Electronic Record

Hardware Documentation Records documenting operational and maintenance requirements of computer hardware such as operating manuals, hardware/operating system requirements, hardware configurations, and equipment control systems.

D





Input Documents Records designed and used solely for data input and control when the data processing unit provides centralized data input services and original records are maintained by the program unit.

Until All Data has been Entered into the System and Verified

Master Files Computer files containing organized and consistent sets of complete and accurate electronic records which replaces or serves in lieu of a textual record.

Maintain for Length of Retention for Textual Records

Microfiche (microfilm)

Retain microfiche in accordance with the retention period applicable

to the subject of the microfiche. Regarding medical records, District of Columbia regulations specifies

that medical records must be retained for ten years following

discharge either in the form of the original record or in the form of a

microfilm or photo static copy.

Network Circuits Inventory Records containing information on network circuits including circuit number, vendor, type of connection, terminal series, software, contact person, and other relevant information about the circuit.

D

Network Implementation Files Records used to implement a computer network including reports, diagrams, of network, and wiring schematics.

D

Operating System and Hardware Conversion Plans Records relating to the replacement of equipment or computer operating systems.

E

Output Records For Computer Production Reports showing transactions that were accepted, rejected, suspended, and/or processed.

E

Processing Files Electronic files used to produce a master file, including, but not limited to, work files, maintenance and test files, print files, and intermediate input/output records. Includes: routine or benchmark files used to test system performance; files which facilitates processing of a particular job or system run, but which does not add to, or delete from, or substantially modify information in a master file.

E

Project Files Records created and used in the development, redesign, or modification of automated systems or applications. Includes project management records, design documentation, feasibility studies, justifications, user requirements, routine status reports, memos, and correspondence. The type(s) of items to be retained will be specified in the Information Systems Standards.

E


E

29 C.F.R. §§1627.3, 516.2-6(FLSA) and 516.11-29 Maybe move to 1.5.7 Salary Administration

Wage statements, itemized Must be kept at least 3 years. E

Maybe move to 1.5.7 Salary Administration





Source Documents For Electronic Records Documents used for the creation of electronic records by data entry or electronic imaging.

Follow the Retention for the Type of Record

System Activity Monitoring Records Electronic files or automated logs created to monitor computer systems such as print spool logs, console logs, tape activity logs, etc.

E

Technical Documentation Records adequate to specify all technical characteristics necessary for reading or processing of electronic records and their timely, authorized disposition. The type(s) of Technical Documentation types to be retained will be specified in the Information System Standards.

Retained for Full Retention of Master Files; See INS-10-08

Training Course Information Memoranda, flyers, catalogues, registration forms, rosters, and other records documenting training courses provided users of electronic records systems.

E

Y2K Documentation Records created or used in the identification and correction of potential and actual Y2K-related issues. These records may include, but are not limited to: Y2K testing reports, testing plans, testing workpapers, quality assurance reports, conversion reports, audit trail records, manuals, training materials, project files, project updates and schedules, contingency plans, data remediation records, vendor certifications, hardware and software documentation, surveys, presentations, correspondence, meeting minutes, analyses, and reference files.

E

1.7 Legal


Applications E 29 CFR §§1620.21

and 1602.14 Compliance - Congressional Hearings Records related to congressional hearings conducted about the company.

C

Compliance Federal Investigations Records related to federal investigations of company activities.

D

Compliance Reports/Forms Submitted to Government Internal copies of legally required reports or forms submitted to government agencies.

C

Development Acquisition/Merger/Divestiture Due Diligence Due diligence and legal research files related to corporate acquisitions, mergers, or divestitures.

B

Development Closing Documents Final record copy of agreements for all corporate acquisitions, mergers, divestitures, and joint ventures including real estate closing documents.

A

Development Joint Venture Due Diligence Due diligence and legal research files related to joint venture deals.

B

Development Limited Partnership Due Diligence Due diligence and legal research files related to limited partnerships.

B





Ethics & Compliance Investigation Case Files Records related to Ethics & Compliance investigations into alleged violations including Alert Line telephone complaints.

D

1.7.1 Business-Organization


Articles of Incorporation Records detailing the terms and conditions under which a corporation is formed and organized.

A

Board of Directors Meetings Records summarizing the proceedings at board of directors meetings.

A

Bylaws Records describing detailed procedures, structures, and responsibilities for operating the corporation.

A

Certificates of Incorporation Documents created by corporate officers and later filed in a designated public office as evidence of corporate existence.

A

Corporate Seals Official corporate seals used to authenticate official company documents.

A

Dividend Records Records indicating payment of dividends to shareholders.

D 26CFR 301.6501(E)-1

Minute Books Records summarizing the proceedings at directors or shareholders meetings.

A

Proxies Records documenting the transfer of voting rights from one party to another.

D

Qualifications to Do Business Records and certificates indicating the company is qualified to do business in a state.

A

Securities and Exchange Commission Audit Work papers Work papers for Securities and Exchange Commission audits.

C

Securities and Exchange Commission Filings Copies of records filed with the Securities and Exchange Commission and supporting documentation related to the issuance of company stock for public sale and annual financial reporting requirements.

A

Shareholders Meetings Records summarizing the proceedings at shareholders meetings.

A

Voting Records Records detailing the votes taken by the board of directors or shareholders.

A

1.7.2 Contracts/Agreements


Abandoned negotiations

E





Buy/Sell Agreements Contracts stating the terms and conditions affecting the transfer of ownership in a privately held corporation or partnership.

C

Change Orders Contracts, executed after the initial contract, that change the terms and conditions stated in the initial contract.

D

Contract Compliance Records demonstrating compliance with the terms and conditions of contracts.

D

Contract Negotiations and Documentation Records related to the development, negotiation, acceptance, changes, and implementation of contracts.

H

Contracts affixed with corporate seal C

Contracts/Agreements - General General contracts or agreements that do not fall under a more specific category.

D

Deeds Records that legally transfer ownership of property.

A Refer to 1.7.9. –

Real Estate

Easements Contracts permitting one party to enter onto a portion of the property of another for a stated purpose.

A Refer to 1.7.9. –

Real Estate

Employment Contracts Contracts between the employer and employees specifying terms and conditions of employment.

D

Executed contracts (including affiliation agreements)

D 42 C.F.R. §413.20

Government Contracts Contracts with government entities.

D

Leases Contracts specifying the terms and conditions under which the owner of property grants possession of the property to another for a specified period of time.

D Refer to 1.7.9. –

Real Estate

Leases – equipment

D 42 C.F.R. §413.20

Managed Care Contracts Contracts between the company and insurance companies in which the company agrees to provide medical care to insurance members based on contracted rates.

D

Mortgages Contracts specifying the terms and conditions under which one party lends money to another for the purchase of property.

D Refer to 1.7.9. –

Real Estate

Promissory Notes Contracts specifying the terms and conditions under which one party lends money to another.

D





Property Improvement Contracts Contracts specifying the terms and conditions under which one party will provide service for improvement to property.

D

Property Titles Records documenting the ownership of property.

A

Purchase orders

D

Sales Contracts Contracts between the company and other parties, normally involving the sale of goods or services covered by the Uniform Commercial Code.

D

Warranties Contracts accompanying the purchase of goods that specify the terms and conditions that apply in case the goods prove to be defective during the warranty period.

D

1.7.3 Corporate 1.7.4 Copyrights/Trademarks/Patents


Copyright Records Records of rights conveyed by the government granting exclusive rights to publish material.

A 35 USC 286

Patents Records of rights conveyed by government granting exclusive rights to the patent applicant to make, use, and sell products during the life of the patents.

A 35 USC 286

Patent Agreements Contracts conveying rights to products based on patents that have been previously been issued to others for those products.

A 35 USC 286

Patent Applications Copies of applications and supporting documentation filed with appropriate government agencies asserting exclusive rights to products and requesting the issuance of patents.

A 35 USC 286

Trademark Records Records of rights conveyed by government granting exclusive ownership of a mark, motto, device, or emblem.

A 35 USC 286

1.7.5 Insurance Records


Administrative files

Closure + E

Arbitration files

B

Certificates of Insurance Certificates that provide legal proof of insurance coverage.

B





Collection judgments Until Discharged

Employment and general litigation cases

Closure + E

Fidelity Bonds Insurance policies indemnifying the company against loss arising from the acts of employees holding positions of trust.

B

Incident reports

A 45 C.F.R. §74.20

Insurance Claims Detailed information regarding the filing of insurance claims.

B

Insurance Companies–Information General records describing sources from which to obtain insurance.

H

Insurance Policies – Active Insurance policy documents for active policies.

D

Insurance Policies – Expired/Canceled Insurance policy documents for policies that have been canceled or have expired.

B

Insurance Policies -- Correspondence General correspondence related to insurance coverage.

B

Insurance Reports & Analysis Insurance reports and analysis including claims reports, stop loss reports, and analysis.

D

Insurance Contractual/Adjustment Discount Report Lists all system-generated insurance contractual adjustments or discounts for the report date.

E

Insurance Plan Activity Analysis Insurance activity information for all primary, secondary, and tertiary payers on file at the facility.

D

Insurance Precertification/Verification Report Lists inpatient accounts that require insurance precertification, verification, or recertification as specified by the account’s insurance plan or as indicated during patient registration.

E

42 C.F.R. §§52.8, 526.6 and 57.215 Refer to 1.7.7 – Litigation/Claims Files

Insurance Review Work-list Report Lists accounts with pending denial claims. Includes accounts with claims in review.

E

Policies of insurance – all others

A

Policies of insurance – professional liability

A

Reports of self-insurance funds

A

Settlement agreements and releases

A





Surety Bonds Bonds posted to indemnify against the failure to perform specified terms and conditions.

B

Treasury - Property Loss Reserves Records related to insurance property loss reserves.

D

Workers Comp claims files

B




1.7.6 Intellectual Property


Assignment agreements

Duration +E

Copyrights

B 17 U.S.C. §507

Patents

A

Service mark/trademarks

A

Warranties

C

1.7.7 Litigation/Claims


Court Case Files Detailed records describing the proceedings of cases gone to trial.

B 28 USC 2401

Final Judgments/Settlements/Court Orders Records specifying final judgments, settlements, or orders related to or resulting from litigation.

B 28 USC 2401

Grievances Records claiming wrongdoing and requesting compensation for matters other than law suits.

F G

8 USC 2401

Malpractice Claims Records detailing claims of medical malpractice filed against the company.

B

28 USC 2401 Refer to 1.7.5 – Insurance Records

1.7.8 Projects


Hospital/Facility Legal Files Records regarding legal matters or legal projects related to hospitals or facilities.

B

Legal Opinions Records resulting from legal projects, which document the specific legal advice provided.

D

Working Papers Supporting documentation prepared by the legal department while undertaking legal activities.

H

1.7.9 Real Estate


Appraisals

E

Deeds A

Refer to 1.7.2 –Contracts/Agreements

Easements A


Leases

Current + D Refer to 1.7.2 –Contracts/Agreeme





nts Mortgages Date Paid + E


Purchase agreements for real property

D

Title insurance

A

1.8 Marketing


Advertising Campaigns Records describing programs or campaigns for advertising products and services.

D

Advertising Price Lists Lists detailing current prices for products and services.

D

Community Relations Records related to participation or promotion of community activities, charitable contributions, civic organizations, etc.

D

Company Publications Publications produced by the company such as newsletters, journals, magazines, etc.

E

Customer Complaints/Problems Records documenting customer complaints or problems, and remedial action taken.

D

Customer Relations Customer Lists Records of customers who have purchased products or services.

D

Customer Relations Orders Records of orders placed by customers.

D

Employee Relations Records related to communications with and programs for employees such as newsletters, letters from management, etc.

E

Government Relations - Correspondence Records related to communications with government agencies.

E

Government Relations - Legislation and Regulation Records related to the monitoring of government legislation and regulation.

H

Government Relations - Political Action Committees Records related to activities and donations to political action committees. Notify Risk & Compliance of any such records.

D 11 CFR 102.9; 11 CFR 104.14

Industry Relations Records related to business associations and other cooperative efforts with other organizations in the industry.

E





Market Research Data & Work papers Work papers used to construct market research reports.

H

Market Research Reports Reports containing information obtained through marketing surveys used to formulate marketing strategies.

E

Marketing Plans Records related to future marketing promotions.

E

Promotional Materials Records documenting sales brochures, catalogs, and price lists.

D

Proposals - Pending Records documenting proposals or quotations provided to customers that specify terms and conditions under which the company will provide products and services.

E

Publicity - News Releases Copies of official news releases given to the media to announce company related news and events.

E

Publicity - Newspaper Clippings Copies of published news stories about company events and/or news.

E

Publicity - Photographs Copies of photographs, including negatives, appropriate for use in publicizing individuals within the organization or organization activities.

E

Publicity - Slide Presentations Slide presentations given by company employees depicting activities of the organization.

E

Publicity - Speeches Copies of public speeches given by company officials.

E

Sales Reports Reports detailing sales activity for a particular period of time.

E

Trade Shows Records related to trade shows including contracts, costs, activities, and evaluations.

E

1.8.1 Advertising


Hospital newspapers, ads and brochures

D

Clippings (historical)

A

Contributor records

A

Permission to release information/photographs

D

Photographs – institutional

A

Press Releases

E





Publications (in-house)

A

1.8.2 Consulting Nurse & Health Information & Referral Services 1.8.3 Public Relations

1.9 Philanthropy

1.9.1 Grant Records


Health and Human Services (financial records, supporting documents, statistical records, equipment purchases)

D 45 C.F.R. §74.20

Public health service grants, National Cancer Institute

E--after conclusion

42 C.F.R. §§52.8, 526.6 and 57.215

Bank Deposits Bank deposit record, summary reports, and work papers.

D

26 CFR 301.6501(E)-1

1.9.2 Fundraising Events Fundraising Events – Attendance Lists, Sign-In Sheets, Etc.

E

1.9.3 Other Events Philanthropy Events – Attendance Lists, Sign-In Sheets, Etc.

E

2.0 Finance 2.1 Accounting

2.1.1 Banking


Bank Deposits Bank deposit record, summary reports, and work papers.

D

26 CFR 301.6501(E)-1

Bank Reconciliations Work papers and reports for bank account reconciliations.

D

26 CFR 301.6501(E)-1

Bank Statements Statements produced by financial institutions detailing transactions by account.

D

26 CFR 301.6501(E)-

Bank Transaction Notices Written confirmation notices of all bank account transactions.

D

26 CFR 301.6501(E)-1

Check Copies/Stubs Copies of checks or stubs indicating payee, amount, date, and purpose.

E





Check Registers Records listing individual checks issued, including payee name, date, amount, and purpose.

D

26 CFR 301.6501(E)-1

Checks - Paid/Cleared Checks that have been cashed and returned by the bank.

D

26 CFR 301.6501(E)-1

Summary Information Summary information regarding banking transactions that are not primary proof of transaction.

E

Wire Transfers Records documenting the electronic transfer of funds.

D

26 CFR 301.6501(E)-1

2.1.2 Capital Property


Acquisitions Records documenting the purchase of property and equipment.

D

26 CFR 1.167(A)-11,12; 26 CFR 301.6501(E)-1

Capital Asset Records Records documenting the purchase and sale of property and equipment, including depreciation, improvements, tax credit, and depletion.

D

26 CFR 1.167(A)-11,12; 26 CFR 301.6501(E)-1

Depreciation Schedules Reports detailing the depreciation, gain/loss, and sale of fixed assets.

D

26 CFR 1.167(A)-11,12; 26 CFR 301.6501(E)-1

Depreciation Work papers The work papers for entering the fixed asset depreciation schedules.

D

26 CFR 1.167(A)-11,12; 26 CFR 301.6501(E)-1

Fixed Asset Schedules Schedule of annual fixed asset additions.

D

26 CFR 1.167(A)-11,12; 26 CFR 301.6501(E)-1

Material Transfer Files Records documenting the physical transfer of material and property from one location to another and the related transfer of accounting charges from one account to another.

D

26 CFR 1.167(A)-11,12; 26 CFR 301.6501(E)-1

Property Inventory Records documenting the type, model, and location of property and equipment.

D

26 CFR 1.167(A)-11,12; 26 CFR 301.6501(E)-1

Property - Sold Records related to the sale of property.

D

26 CFR 301.6501(E)-1

Construction Accounting Reports Construction in progress reports, cost analysis reports, and other construction account analysis reports.

D

26 CFR 301.6501(E)-1

Construction Accounting Work papers Work papers used to create construction accounting reports and perform account analysis.

D

26 CFR 301.6501(E)-1





Capital Expenditure Receipts Receipts for all capital expenditure transactions.

D

26 CFR 1.167(A)-11,12; 26 CFR 301.6501(E)-1

Capital Expenditure Reports Capital expenditure summary reports by division and by facility.

D

26 CFR 1.167(A)-11,12; 26 CFR 301.6501(E)-1

2.1.3 General


Account Analysis and Work papers Work papers and reports used for account analysis.

D

26 CFR 301.6501(E)-1

Accounting Earnings Review Monthly accounting/financial operations reports.

D

26 CFR 301.6501(E)-1

Accounting Earnings Review Work papers Work papers used to construct the accounting earnings review.

D

26 CFR 301.6501(E)-1

Trial Balances Summary records of account balances by debits and credits.

E

Supply Requisitions Supply requisition records including office and material management supply requisitions.

E

Audit Reports - External Records reviewing and documenting financial information created as part of an audit performed by an outside person or organization.

D 26 CFR 301.6501(E)-

Audit Reports – Internal Records reviewing and documenting financial information created as part of an audit performed by a person in the organization.

D

Audit Work papers Records that support the audit reports and that were prepared as part of the audit process.

E

Bids - Accepted Proposals from outside vendors that indicate the terms and conditions under which they will supply goods or services.

E

Bids - Rejected Proposals submitted by outside vendors that were not accepted.

H

Budget and Variance Reports Reports detailing budgeted and actual expenditures with variance.

E

Budget Work papers Records produced to prepare or support the approved budgets.

E Keep as E

Budgets - Approved Records projecting income and authorizing expenditures for the organization.

E





Budgets - Department Copies Department copy of approved budget.

E

Catalogs/Price Lists Promotional materials from vendors that include standard pricing for items.

H

Corporate Debt Work papers and Reports Reports and work papers related to the analysis of corporate debt.

D

26 CFR 1.167(A)-11,12; 26 CFR 301.6501(E)-1

Credit Agency Reports Credit reports produced by outside credit agencies.

E

Financial Plans Records stating the financial plans that the organization will follow.

E

Financial Reports and Work papers General reports and work papers related to financial data and transactions.

D 26 CFR 301.6501(E)-1

Financial Statements - Annual Records stating financial condition of the organization at the end of the fiscal year. Generally, will become the Certified Financial Statement after the audit has been completed.

D

26 CFR 301.6501(E)-. Check Cite.

Financial Statements - Annual - Certified Records stating the certified or official financial condition of the organization at the end of the fiscal year.

D

26 CFR 301.6501(E)-1 Check Cite.

Financial Statements - Monthly/Quarterly Records stating financial condition of the organization at the end of the month or quarter. The annual financial statements replace these reports.

E Check Cite.

Forecasts Records projecting expenses and income over a specified period.

E

Futures/Options Records documenting investments in futures or options including purchase information, annual statements, and investment reports.

D

26 CFR 1.167(A)-11,12; 26 CFR 301.6501(E)-1

Letters of Credit Negotiable instruments requesting credit and detailing repayment conditions.

D

26 CFR 1.167(A)-11,12; 26 CFR 301.6501(E)-1

Loan Agreements Contracts with an outside lending institution to borrow money, stating the terms and conditions of the loan.

D

26 CFR 1.167(A)-11,12; 26 CFR 301.6501(E)-1

Loan Applications Records submitted to an outside lending institution to borrow money.

D

26 CFR 1.167(A)-11,12; 26 CFR 301.6501(E)-1





Mortgage Records Records of the financing of property purchased.

D

26 CFR 1.167(A)-11,12; 26 CFR 301.6501(E)-1

Notes, Canceled Records documenting former financing obligations that have been paid off.

D 26 CFR 301.6501(E)-1

Profit and Loss Statements Financial statements detailing financial conditions of the organization.

D 26 CFR 301.6501(E)-1

Purchase Orders Records of purchasing including approved bids, specifications, change orders, delivery, etc.

E

Purchase Orders - Copies Departmental copies of purchase orders.

E

Purchase Requisitions Records requesting the purchase of goods or services.

E

Real Estate Records documenting investments in real estate including purchase information, statements, and investment reports.

A

26 CFR 1.167(A)-11,12; 26 CFR 301.6501(E)-1 Refer to 1.1.1.6.

Securities Records documenting investments in securities including the proof of ownership, purchase information, annual statements, and investment reports.

D

26 CFR 1.167(A)-11,12;

26 CFR 301.6501(E)-1

Shipment Documentation Records documenting receipt of goods.

E

Strategic Development Files Records related to strategic financial development.

E

2.1.4 Intercompany


Intercompany Invoices Invoices detailing intercompany account transactions.

D

26 CFR 301.6501(E)-1

Intercompany Reconciliations Reports and workpapers used to reconcile intercompany accounts.

D

26 CFR 301.6501(E)-1

2.1.5 Journals/Ledgers


Account Ledgers Records used to summarize charges to individual accounts.

C

26 CFR 301.6501(E)-1

Account Ledger Index Lists accounts from the Account Ledger in alphabetical order by patient name.

C 26 CFR 301.6501(e)-1





Accounts Payable General Ledger Interface Report Computer generated reports of all accounts payable entries to the general ledger. Includes G/L interface report, distribution history, trial balance register by vendor, A/P distribution to G/L, distributions added to history, and aged trial balance.

D 26 CFR 301.6501(E)-1

Accounts Payable Ledgers Record summarizing accounts payable transactions.

C

26 CFR 301.6501(E)-1

Accounts Payable Voucher Register Control Log Work papers to the A/P - G/L interface reports.

E

Accounts Receivable Ledgers Record summarizing accounts receivable transactions.

C

26 CFR 301.6501(E)-1

Adjusting Journal Entries Correction entries to the general ledger.

C

26 CFR 301.6501(E)-1

Balance Sheets Summary document showing assets, liabilities, and equity.

C

26 CFR 301.6501(E)-1

Cash Journals Records detailing cash account transactions.

C

26 CFR 301.6501(E)-1

Cash Receipt Journal Entries Cash receipt transaction entries to the general ledger.

C

26 CFR 301.6501(E)-1

Chart of Accounts Listing of the account names and codes used in the accounting system.

C

26 CFR 301.6501(E)-1

General Ledger/Subsidiary Ledgers Consolidated, cumulative general ledger or subsidiary ledgers published at year-end.

C

26 CFR 301.6501(E)-1

Intercompany Journal Entries Records detailing intercompany account transfers in the general ledger.

C

26 CFR 301.6501(E)-1

Journal Entries Records detailing transactions in the general ledger.

C

26 CFR 301.6501(E)-1

Journals (general)

D

Ledgers (general)

D

Monthly Close Package Accounting work papers processed at the closing of the monthly general ledger.

D

26 CFR 301.6501(E)-1

Payroll Registers Records detailing payroll amounts, deductions, and taxes for each employee.

C

26 CFR 301.6501(E)-1

2.1.6 Payroll


Checks – cancelled – payroll

D





Garnishment Accounting Records related to the withholding and payment to third parties of amounts garnished from employee wages as required by court order.

D 26 CFR 301.6501(E)-1

Garnishment Orders Legal orders received from courts requiring specified amounts of money to be withheld from employee salaries to satisfy a debt.

E

Payroll Checks - Copies Copies of issued payroll checks.

B

Payroll Checks – Paid/Cleared Checks issued for payroll that have been cashed and returned by the bank.

D 26 CFR 301.6501(E)-1

Payroll Reconciliations Payroll reconciliation reports, work papers, and payroll edits.

D

26 CFR 31.6001-1; 26 CFR 301.6501(E)-1

Payroll Records Records documenting payments for payroll over time including dates, employee names, withholding amounts and purpose, final check amount, and other related information. Includes payroll itineraries and pay stubs.

D

26 CFR 31.6001-1; 26 CFR 301.6501(E)-1

Payroll Reports and Work papers Includes consolidated payroll outstanding/paid report, payroll deletes, payroll control log, payroll void reports, and payroll work papers.

D

26 CFR 31.6001-1; 26 CFR 301.6501(E)-1

Time Cards Records indicating time worked, including absences, vacation, sick leave, etc. Includes payroll tickets, time slips, and time edits.

D 29 CFR 405.9; 29 CFR 516

2.2 Accounts Receivable


Legal Citations

Accounts receivable

D 42 C.F.R. §413.20

Accounts Receivable Management Report Work papers Work papers used to create the accounts receivable management reports.

D

26 CFR 301.6501(E)-1

Accounts Receivable Management Reports Includes accounts receivable indicators by region and facility report, accounts receivable status reports, and other accounts receivable analysis reports.

D

26 CFR 301.6501(E)-1

Accounts Receivable Reconciliations Reports and work papers used to reconcile accounts receivable accounts.

D

26 CFR 301.6501(E)-1

Attachments, assignments and garnishments

E -- After Satisfied

42 C.F.R. §5166

Capital expenditures

D 42 C.F.R. §413.20.

Cash Receipts Records documenting cash payments received.

D 26 CFR




301.6501(E)-1 Cashiers’ tapes from bookkeeping machines

E

Charge (slips) to patients

D

Checks – cancelled – other

D

Checks – cancelled – taxes, capital purchases, important contracts

A

Claims and charges to patients, fiscal intermediaries, third-party payers, etc. Source documents for electronic claims submission should be retained for 3 years.

D 22 C.C.R. §51502.1

Collective bargaining agreements Must be kept at least 3 years.

A 29 C.F.R. §5165.5

Correspondence – credits and collections

D

Correspondence – general

D

Correspondence – insurance

D

Cost statistics/reports

D 42 C.F.R. §413.20

Credit Advices Records documenting payments that result in credit due.

D

26 CFR 301.6501(E)-1

Depreciation records

D 42 C.F.R. §413.20

Disbursements (unclaimed/returned) Unclaimed checks and disbursements escheat to state after 3 years; the state then attempts to notify recipients.

E

Equipment depreciation records A -- Life of Equip + D

Federal and state tax reports D

IRS Code §31-6001-1(e)(2); 26 CFR §1.6001-1

Federal and state tax returns

A 42 C.F.R. §413.20

Income (daily summary)

D

Income tax returns

A

Invoices Copies of invoices sent to customers, including support documentation.

D

26 CFR 301.6501(E)-1

Invoices – accounts receivable/payable

D

Invoices – fixed assets A -- Life of equip + D

IRS determination letters

A 26 U.S.C. 6501

Medicare cost report records. The records that must be retained are: Billing material: hospital copies of claim forms, supporting documents and forms (e.g., charge slips, daily patient census records, and other business and accounting records referring to specific claims).

E -- 5 Years after the Month

the Medicare Cost Report is

Hospital Manual, HIM-10 §§413, 413.1; Skilled Nursing Facility




Cost report material: all data necessary to support the accuracy of entries on annual cost reports including original invoices, cancelled checks, hospital copies of material used in preparing annual cost reports, and other similar cost items, schedules and related worksheets, and contracts or records of dealings with outside sources of medical supplies and services or with related organizations.

Medical records material: utilization review committee reports, physicians’ certifications and re-certifications, discharge summaries, clinical and other medical records relating to health insurance claims.

Hospital physician material: hospital physician agreements on which Part A and Part B allocations are based.

Filed with the Inter-mediary

Manual, HIM-12 §§545-545.4

Patient invoices

D 42 C.F.R. §413.20

Posting audits

D

Public contracts (employee records) Retention requirement may be longer, depending on public contract law or terms of public contract.

D

Rate schedules Must be kept at least 2 years.

D 29 C.F.R. §516.6

Registers

D

Reports on departmental statistics

Current + E

Sales Receipts Records documenting sales, including quantity, description, and amount.

D 26 CFR 301.6501(E)-1

Social security reports Must be kept at least 4 years.

D -- After taxes are

paid

26 C.F.R. §31.6001-1

Tax return working papers

D

Unemployment tax records

E

Vouchers – capital expenditures A -- Life of Item + D

Vouchers – cash

D

Vouchers – other checks

D

Welfare agency records

D

Withholding and social security tax reports E IRS Code §31.6001-1(e)(2)

Withholding tax statements (W-2 forms) Must be kept at least 4 years.

E 26 C.F.R. §31.6001-1

Withholding tax-exemption certificates (W-4 forms) Must be kept at least 4 years.

D 26 C.F.R. §31.6001-1

Workers’ compensation records, self-insureds claims and claims logs 2 years after inactive for originals, then can microfilm for access indefinitely

D

2.3 Accounts Payable





Legal Citations

Vouchers/Invoices Documents received from creditors requesting payment and sent to the Accounting Department for payment.

D

26 CFR 301.6501(E)-1

Vouchers/Invoices - Department Copies Duplicate copies of payable documents sent to Accounting for payment.

E

Vendor Files and Reports Reports and work papers for accounts payable vendors.

D 26 CFR 301.6501(E)-1

Cash Disbursements Records documenting cash payments to creditors.

D 26 CFR 301.6501(E)-1

Contract Accounting Records Records documenting the costs related to specific tasks or line items specified in contracts.

D 26 CFR 301.6501(E)-1

Cost Accounting Records Documents and reports detailing company operating costs, including both direct and indirect costs.

D 26 CFR 301.6501(E)-1

Credit Card Charge Slips Vendor copy of credit card forms documenting the items purchased, price, and customer signature (or telephone authorization).

D 26 CFR 301.6501(E)-1

Credit Card Statements Statements received from credit card companies indicating charges to credit cards.

D 26 CFR 301.6501(E)-1

Donations Records describing and documenting charitable donations.

D 26 CFR 301.6501(E)-1

Expense Reports Records detailing business expenses incurred by employees generally while traveling on company business.

D 26 CFR 301.6501(E)-1

Petty Cash Records Records documenting the disbursement of cash from the petty cash fund.

D 26 CFR 301.6501(E)-1

Property Taxes Records documenting the payment of property taxes.

D 26 CFR 301.6501(E)-1

Unemployment Insurance Payments Records documenting the payment of unemployment insurance.

D 26 CFR 301.6501(E)-1

Workers Compensation Insurance Payments Records documenting the payment of workers compensation insurance premiums.

D

26 CFR 301.6501(E)-1

2.4 Business Office – Revenue


Legal Citations

72-hour Report Lists all inpatient accounts with a financial class of 01 Medicare, 02 Medicare DPU, and 03 Medicaid that had outpatient visits during the previous 72 hours.

C 42 CFR 413.20 42 CFR 413.24





Legal Citations

Account Notes Report Lists account notes and action requests generated by Patient Accounting Services.

E

Account Work Again List Lists accounts flagged for special follow-up activity prior to the next scheduled collection series follow-up. An account appears on the list only one time.

E

Accounts Receivable Aging Report Accounts receivable aging information as of preliminary close by financial class and service code.

D 26 CFR 301.6501(e)-1

Accounts Receivable Detail Activity List Detailed information about weekly and week to date final billed accounts.

E

Action Request Report Lists action requests for information that Patient Accounting Services needs for continued follow-up.

E

Aged Accounts Listing Report List of all active accounts aged 330 days or greater from the date of discharge.

E

Alphabetic Census Report Lists information for active inpatients by patient name and financial class.

D

Alphabetic Cross Reference List Information about the weekly and week to date final billed accounts.

E

Ancillary Charge Report Ancillary charge activity reports include departmental revenue and may be sorted by patient name and/or department.

E

Ancillary Charge Report Lists charges and credits entered in the system and successfully received by Patient Accounting.

E

Bank Deposit Reconciliation Report Summary of all payments received for the day of the report.

E

Batch Control Log Lists totals accepted and any variances that resulted from comparing pre-input totals to totals accepted by the system for the previous day's patient batches.

H

Batch Edit Report "Pre-edit" information about the transaction batches sent to Patient Accounting so that transactions can be corrected and retransmitted prior to nightly processing.

H

Bill Alert Edit Reports Lists unbilled accounts that contain bill alerts by patient, responsible department, and physician.

E

Bill Alert Summary by Error Report Lists summary of bill alerts for all patients by error description.

E

Billing Reports Lists inpatient and outpatient claims by bills, final bills, interim bills, and replacements. Billing Reports include 1500 and UB92 claims.

E





Legal Citations

Bills Generated Report Lists all accounts that had a bill generated on the report date and accounts that were supposed to receive a bill, but did not.

E

Care Unit Census Report Lists all inpatients and observation patients not registered when the Patient Accounting nightly update occurred.

D

Cash Journal Entry Summary Detailed list of journal entries passed to the general ledger.

C 26 CFR 301.6501(e)-1

Cash Receipts Journal Lists all payments received the date of the report.

C 26 CFR 301.6501(e)-1

Central Statement Control Report Lists accounts for which central or historical statements were generated (for facilities that use central or historical statements).

E

Checklist for Daily Balancing Compares certain items from Patient Accounting and General Ledger reports to each other to ensure that the Patient Accounting financial data is in balance.

E

Claim Date Exceptions Report Lists final billed accounts with insurance but no claim submission date. For use by facilities that do not use the claim submission date as the final bill date.

E

Claim Held Accounts Lists accounts with claim forms held due to missing information. Also lists accounts that receive a shell claim form and their charges.

C

Collection Agency New Activity Report Information for accounts that have been placed with, deleted from, or transferred to a collection agency (including tape and non-tape agencies).

E

Collection Agency Payment Register Agency payments, other payments, adjustments, and allowances posted weekly and/or daily for each agency. Includes payment summary with totals for all agencies.

E

Collection Agency Percent Recovery Report Monthly percentages of recovery analysis starting with the month in which turnover to an early out, primary, or secondary agency occurred.

E .

Collection Agency Pre-list Report Lists accounts that are ready to be transferred from early out to primary or from primary to secondary collection agencies.

E

Collection Agency Recovery Analysis Report History of accounts placed to early out, primary, and secondary agencies, including statistics on amounts collected and recalled.

E

Collection Agency Summary Report Summary of account totals for each agency, broken down by aging category.

E





Legal Citations

Collection Series/Agency Report Collection series analysis as of preliminary.

D 26 CFR 301.6501(e)-1

Collection Records Records related to the management and collection of bad debts.

D 26 CFR 301.6501(E)-1.

Daily Acknowledgement Report Lists the contents of the acknowledgement file returned to the corporate office by insurers.

E

Daily Batch Report Lists all patient accounting batches that received error or warning messages during the previous night's processing.

H

Daily Billing Report List of claims generated by electronic processing.

E

Daily Care Reconciliation Report Detailed inpatient information that results in patient day adjustments.

E

Daily Credit Balance Worksheet Worksheet for each account that reached a balance on the report date. Worksheets include total charges followed by any payments, adjustments, allowances, and write-offs that have occurred since the account was final billed.

E

Daily Error Report Lists patient account numbers that were rejected by insurers during the previous day's claims processing.

E

Daily Revenue Analysis Report Lists daily and month-to-date patient days information as well as month-to-date revenue by department.

D 26 CFR 301.6501(e)-1

Daily System Recap Report Summary by patient type of the previous day's interface to the general ledger for accounts receivable, bad debt, and pre-service deposits.

H

Data Transmission Report Confirms successful transmission of transaction files to Patient Accounting, electronic archiving, or any other database system.

H

Delayed Accounts Report Lists final billed accounts that have a delayed patient collection series.

E

Delinquent Collection Account List Lists final billed and delinquent collection accounts by patient, insurance company, and account number.

E

Denied Claims Report Lists denied claims by payer and by denial code.

E

Detail Age Analysis Report Lists all aged accounts and amounts as of month-end, including patient, industrial, and unbilled discharged account detail as well as active account and pre-service account summaries.

D 26 CFR 301.6501(e)-1





Legal Citations

Detail Bill Report Detailed charge information to supplement insurance claims.

D

Detail Collection Agency Listing Report Detailed aged listing of accounts placed with agencies, including total agency balances by aging category.

E

Diagnosis Related Group (DRG) Report Confirms successful transmission of Diagnosis Related Group (DRG) files to Patient Accounting.

H

Discharged Accounts Ready to Bill Report Lists information for unbilled discharged accounts in the ready to bill and final bills on hold sections.

E

Discharged Accounts Report Lists discharged patients, including one-day stays, and leave of absence patients.

D 42 USC 1395cc(a)(1)(I) (ii)

Discounted Bills Report Lists all discounted bills produced for patients and inpatients on the report date.

E

Discounted Procedures Report Year-to-date summary of gross and net revenue billed for rooms and procedures for discounted payers.

D 26 CFR 301.6501(e)-1

Electronic Remittance Advice Processor Error Report Lists errors that occurred when an electronic remittance advice was unable to match the information in the Electronic Remittance Advice Master File.

H

Error Report by Submitter Lists identified claims errors.

E

Fee Schedule Patient Assign Report Lists all accounts, including industrial and client accounts, for which a fee schedule is currently assigned.

E

Fee Schedule/Assign Inactivation Report Lists patient accounts for which an assigned fee schedule was deleted or inactivated on the effective date.

E

Final Bill Alert Exception Reports Lists all accounts past the SUMM days that have not been final billed.

E

Final Billing Exception Report – Aging Account aging information for accounts that have passed SUMM days (suspense days between discharge and final bill) but have not been final billed.

E

Financial Census Report Lists the inpatient and outpatient accounts that have not been billed.

D

General Ledger Detail Transaction Log Lists detailed charge and payment activities by general ledger account number.

E

Guarantor Billing Detail Report Lists all accounts linked for guarantor billing and provides detailed information about each associated account.

E





Legal Citations

Held Claims Report Lists all final billed accounts for which secondary and/or tertiary insurance claims are being held pending primary insurance payment.

D

Incomplete Transfer Report Patient collection accounts that may indicate a transfer to a collection agency or to the bad debt series, but the system is unable to perform the transfer due to insurance tracking the account.

E

Industrial Follow-up List Lists industrial accounts, including accounts with overdue amounts.

E

Interim Billed Accounts Report Lists all outstanding interim bill accounts that insurance tracking has not relieved. Includes unbilled and final billed accounts.

E

Interim Billed Activity Report Lists all interim bill accounts that had activity since the last weekly update. Final billed accounts do not appear on this report.

E

Interim Billing Detail Aging Report Lists all interim billed accounts by aging category. Account aging is based on bill-through date.

E

Late Charge Report Detailed information for late charges not posted to a patient’s account or have not been posted to the general ledger.

E

Leave of Absence Report Lists information on leave of absence status.

D 42 USC 1395cc(a)(1)(I) (ii)

Lockbox Payment Detail Report Lists all payments received by the vendor at the designated lockbox processing site. Daily report is not produced on weekends or holidays.

E

Management Reports Includes management level daily, monthly, and year-to-date statistical analysis for inpatients and outpatients.

D 42 USC 1395cc(a)(1)(I) (ii)

Master File Reports List of changes, errors, warnings, or discrepancies concerning Master Files.

H

Medicare 3-Day Window Report Lists non-combined accounts that may qualify for combined billing under Medicare's regulations for PPS and Non-PPS coverage.

C 42 CFR 413.20 42 CFR 413.24

Medicare Claim Acknowledgement Report Acknowledgement of Medicare electronic claims received by insurers.

C 42 CFR 413.20 42 CFR 413.24 ‘





Legal Citations

Medicare/Medicaid Records Copies of Medicare and Medicaid financial, administrative, and program records associated with claims, reimbursement, and client activities.

C 42 CFR 413.20 42 CFR 413.24 ‘

Minimum Agency Transfer/Small Balance Report Lists accounts automatically written off during the previous week as the result of Agency Default Series and Small Balance Series processing.

E

Monthly Late Charge Analysis Report Lists current month and year-to-date late charges by department.

D 26 CFR 301.6501(e)-1

Monthly Management Report Management level current month and year-to-date statistical analysis for inpatients and outpatients.

E 42 USC 1395cc(a)(1)(I) (ii)

Monthly Medicare Revenue Analysis Report Current month and year-to-date Medicare patient days and revenue information by department.

C

42 CFR 413.20 42 CFR 413.24

Monthly Physician Analysis Summary Statistics for current month and year-to-date inpatient Medicare revenue.

C 42 CFR 413.20 42 CFR 413.24

Monthly Physician Analysis Summary Reports Lists attending physicians by their percentage of total revenue in descending order or by attending physician number and financial class.

D 26 CFR 301.6501(e)-1

Monthly Procedure Analysis Report Current month and year-to-date procedure code analysis for both inpatients and outpatients, including all procedure types.

D 26 CFR 301.6501(e)-1

Monthly Purged Accounts Report Lists accounts at the end of the month that were manually or automatically purged from the system during the month.

E

Monthly Relative Value Analysis Report Current month and year-to-date relative value analysis of procedures for inpatients and outpatients.

D 26 CR 301.6501(e)-1

Monthly Revenue Analysis Report Current month and year-to-date patient days and revenue information by department, service code, employer, insurance plan, and medical specialty.

D 26 CFR 301.6501(e)-1

Occupancy Report Detailed information about patient occupancy by nurse station and by patient type.

D 42 USC 1395cc(a)(1)(I) (ii)

Patient Account List Report Lists all patients, unbilled and final billed, with the date and amount of the last payment as well as the account balance.

E

Patient Accounting to General Ledger Interface Recap Report Summarizes the detail transactions created by Patient Accounting and sent to General Ledger each day.

E

Patient Accounting to General Ledger Interface Reconciliation Report Provides patient-level details for all transactions created by Patient Accounting for the day's interface to the General Ledger.

E





Legal Citations

Patient Activity Report Lists activities performed, such as an attending physician change or a cancelled admission.

D 42 USC 1395cc(a)(1)(I) (ii)

Patient Charge Cards Daily patient charge items entered into a patient accounting system. Information may be used to track hospital inventory.

E

Patient Charge Summary Summary records for patient account charges.

E

Patient Transaction Log Lists charge, payment, allowance, adjustment, and bad debt write-off transactions posted to the general ledger during the month being closed.

D

Payment Calculator Update Status Report Information about payment calculator processing.

E

Payment Exception Report Lists final billed accounts with insurance due where the patient balance is credit, but the total account balance is not credit.

D

Preprocessor Batch/Daily Prep Report Lists batch header information for all batches entered during the day.

H

Pre-Service Daily, Monthly, and Follow-up Accounts Reports Lists pre-service patients that show any charges and/or payments on file, with estimated billing amounts and frequency.

E

Procedure Analysis Report Lists current month and year-to-date procedures by financial class.

D 26 CFR 301.6501(e)-1

Procedure Code Reports Lists or summarizes procedure codes used to link transactions that affect the balance of a patient’s account with the general ledger.

H

Procedure/Revenue Code System/Patient Change Exception Reports Lists procedure codes and descriptions or patients when codes are either missing or not within the valid range of the revenue code.

E

Procedures — No Activity Last 12 Months Report Lists all active procedures that have had no activity in the last 12 months.

D 26 CFR 301.6501(e)-1

Proration Worksheet Detailed proration information for each account's insurance plans.

E

Purged Accounts Report Lists accounts purged as a result of Zero Balance Collection Series processing.

E

Records of Employment (ROE) Exceptions Report Lists patients whose payer information contains discrepancies.

E

Records of Employment (ROE) Received Lists admitted patients for whom the facility has received verification data from third-party payers.

E





Legal Citations

Registrations Activity Report Reports on active and discharged registrations.

E 42 USC 1395cc(a)(1)(I) (ii)

Remittances Received - Detailed Report Report of the electronic remittance advice for Medicare payments.

C 42 CFR 413.20 42 CFR 413.24

Remittances Received Report Lists transmitted remittance advices received by electronic processing for various payer plans.

D 26 CFR 301.6501(e)-1

Reporting Agency Bad Debt Notes Report List of follow-up information for patient accounts entered daily by reporting agencies.

E

Room/Bed Transfer Report Lists information about room/bed transfers.

D 42 USC 1395cc(a)(1)(I) (ii)

System to Patient Accounting Interface Recap Report Total transactions sent to Patient Accounting from the system and the total number of transactions received by Patient Accounting.

E

Third Party Aged Detail Report Detailed aging analysis of third-party liability by patient number.

D 26 CFR 301.6501(e)-1

Third Party Analysis Report Analysis of third-party liability, which includes amounts owed by insurers (primary, secondary, and tertiary) of final billed accounts.

D 26 CFR 301.6501(e)-1

Transaction Change Log Lists journal entries and payment records that changed within the time period between two successive cutoff dates.

D 26 CFR 301.6501(e)-1

Transaction Exception Report Displays the results of an automatic search that the system conducts to locate valid patient account numbers.

H

Unapplied Cash Log/Activity Report Lists the daily unapplied cash activity and provides information about all unapplied cash.

D 26 CFR 301.6501(e)-1

Unbilled Aged Trial Balance Lists all accounts, grouped by insurance plan within financial class, that have not been final billed by preliminary close.

E

Unbilled Discharged Accounts Report Lists all accounts that have been discharged but have not been final billed.

E

Verification Requests Daily listing of patient accounts for which a notice of admission has been transmitted.

E

Weekly Aged Cash Receipts Worksheet Summarizes charges, payments, allowances, policy adjustments, and write-offs into aging categories.

E

Weekly Credit Balance Summary Credit balance account information in summary and analysis sections.

E





Legal Citations

Weekly/Monthly Accounts Receivable Analysis Report Weekly/monthly account analysis and account summary.

D 26 CFR 301.6501(e)-1

Write-off Analysis Report Detailed write-off information.

D 26 CFR 301.6501(e)-1

2.5 Reimbursement – Cost Reports


Legal Citations

Correspondence with Fiscal Intermediaries Correspondence with third party intermediaries contracted with HHS.

D

Correspondence with HHS Correspondence with the Department of Health and Human Services.

D

Cost Report Appeal Work papers Essential work papers used to construct the cost report appeal.

C 42 CFR 413.20; 42 CFR 413.24

Cost Report Appeals Cost Report Appeals filed with HHS.

C 42 CFR 413.20; 42 CFR 413.24

Cost Report Support Papers Support documents used to construct the cost report, but not essential for the appeal or reopening of the cost report.

D

42 CFR 413.20; 42 CFR 413.24

Cost Report Work papers Essential work papers used to construct the cost report.

C 42 CFR 413.20; 42 CFR 413.24

Cost Reports Cost reports filed with HHS for Medicare/Medicaid cost reimbursement.

C 42 CFR 413.20; 42 CFR 413.24

Reimbursement General Files Reference information used by the accountants that is not needed for cost reports or appeals.

D

Reimbursement OIG Requests Copies of information requested by HHS Office of Inspector General.

D

Reimbursement Reports Summary reports detailing reimbursement totals by facility or cost center.

D

Reimbursement Analysis Report Analysis of expected payment and contractual calculations.

E

Reimbursement Worksheet Detailed information about expected payment and contractual calculations.

E

2.6 Tax


Legal Citations





Legal Citations

Tax - Acquisition/Divestiture/Reorganization Tax Research and Work papers Research for acquisitions, divestitures, and reorganizations including due diligence.

D 26 CFR 301.6501(E)-1

Tax – Compliance -- Tax Account Reports and Analysis Reports and analysis related to specific tax accounts.

C 26 CFR 301.6501(E)-1

Tax – Federal -- Employment Tax Reports and Work papers Work papers and summary reports for federal employment tax returns.

C 26 CFR 31.6001-1

Tax – Federal -- Employment Tax Returns Federal employment tax returns.

C 26 CFR 31.6001-1

Tax – Federal -- Employment Tax Withholding Certificate Certificate documenting permission to withhold taxes from payroll.

D 26 CFR 31.6001-1

Tax – Federal -- Excise Tax Reports and Work papers Work papers and summary reports for federal excise tax returns.

C 26 CFR 301.6501(E)-1

Tax – Federal -- Excise Tax Returns Federal excise tax returns.

C 26 CFR 301.6501(E)-1

Tax – Federal -- Income Tax - Correspondence Correspondence related to federal income tax returns.

C 26 CFR 301.6501(E)-1

Tax – Federal -- Income Tax - IRS Audit Reports Reports prepared by IRS containing tax audit findings, conclusions, and agreements.

C 26 CFR 301.6501(E)-1

Tax – Federal -- Income Tax - Protests/Appeals/Claims for Refunds Records related to protests, appeals, and claims for refunds from federal income taxes.

C 26 CFR 301.6501(E)-1

Tax – Federal -- Income Tax Reports and Work papers Work papers and summary reports for federal income tax returns.

C 26 CFR 301.6501(E)-1

Tax – Federal -- Income Tax Returns Federal income tax returns.

C 26 CFR 301.6501(E)-1

Tax – Federal -- Research Files Research files for federal tax issues.

D 26 CFR 301.6501(E)-1

Tax – Foreign -- Foreign Tax Returns Foreign tax returns.

C

Tax – Foreign -- Foreign Tax Work papers Work papers and summary reports for foreign tax returns.

C

Tax – General -- Tax Compliance Files Records related to tax compliance issues.

C 26 CFR 301.6501(E)-1

Tax - State/Local -- Audit Reports and Work papers Audit reports and work papers for state and local taxes.

C





Legal Citations

Tax - State/Local -- Income and Franchise Tax Returns State and local income tax or franchise tax returns.

C

Tax - State/Local -- Income and Franchise Tax Work papers Work papers and summary reports for state and local income or franchise tax returns.

C

Tax - State/Local -- Property Tax Returns Property tax returns.

C

Tax - State/Local -- Property Tax Work papers Work papers and summary reports for property tax returns.

C

Tax - State/Local --- Research Files Research files for state and local tax issues.

D

Tax - State/Local -- Sales and Use Tax Returns Sales and Use tax returns.

C

Tax - State/Local -- Sales and Use Tax Work papers Work papers and summary reports for sales and use tax returns.

C

Tax - State/Local -- State Unemployment Tax Reports and Work papers Work papers and summary reports for state and local taxes.

C

3.0 Patient Specific Records


Legal Citation

Patient records, including: Admission records Autopsy reports (and consents for autopsy) Consent forms Consultation reports Labor and delivery records Laboratory notes Nurses’ notes Pathologists’ reports Patient histories Patient identification information Physical examinations Physicians’ orders Progress notes Reports of all other tests: EKG, EEG, etc. Summary or final diagnoses Surgical records, complete with anesthetic records, findings, operative procedures, postoperative diagnoses, preoperative diagnoses, and tissue diagnoses Temperature charts Vital sign sheets X-ray reports

Adults – F Minors – G

Adults – Patient Medical Records Complete health records for adult patients.

F RCW 70.41.190

Appointment books (patients) E





Legal Citation

Autopsy Records Records related to autopsies.

D—after Autopsy

Autopsy records – gross photographs

D

Autopsy records – paraffin blocks

D

Autopsy records – reports

D

Autopsy records – slides

D

Autopsy records – wet tissue (stock)

E

Autopsy records – wet tissue (whole organs)

2 months after final report

Blood bank – donor and patient ABO and RH compatibility results/antibody screens

E

Blood bank – donor and recipient records

A .

Blood bank – quality control records

E

Blood bank – records of employee signature, initials and identification codes

A

Blood bank – records of permanently deferred donors

A

Cardiac Catheterization Films Films taken before, during, and after a heart catheterization procedure.

F G

Child Abuse Reports Records related the identification and treatment of child abuse victims.

G RCW 70.41.190

Clinical laboratory and pathology records – accession records

E

Clinical laboratory and pathology records – inpatient requests/electronic test orders E

Clinical laboratory and pathology records – instrument maintenance records

E

Clinical laboratory and pathology records – manual back-up forms

E

Clinical laboratory and pathology records – outpatient test requisitions and advance beneficiary notices D

Clinical laboratory and pathology records – patient test records/reports

D

Clinical laboratory and pathology records – proficiency testing results

E

Clinical laboratory and pathology records – quality control records

E

Cytology – fine needle aspiration slides

D

Cytology – reports Refer to 1.1.1.10





Legal Citation

D Laboratory Cytology – slides (negative or unsatisfactory)

E Refer to 1.1.1.10 Laboratory

Cytology – slides (positive or suspicious)

E Refer to 1.1.1.10 Laboratory

Diagnostic Images Diagnostic images such as x-rays. Interpretations of films are found in the Patient Medical Record. Films may cover any disease or injury and includes mammograms of returning patients.

E

Dialysis Records Records related to dialysis treatments.

F G

RCW 70.41.190

Disease Index, Operative Index, Physician’s Index, Diagnostic Index, Number Index Health records indexes for disease, operations, and physicians.

A

EEG and EKG strips

D

Emergency Room Logs Records related to the emergency room.

D

Emergency Run Reports Reports on patients revived, and/or attempted to be revived, by the administration of drugs, both inter-cardiac and intravenously, and by using counter-shock treatment. Includes all other patients who accepted service from an EMT, EMS or Air-Medical Provider, or a paramedic.

D

Equipment calibration records

E

Equipment inspection reports

E

Fetal Heart Monitoring Reports/Strips Records related to fetal heart monitoring. Includes actual strips generated by fetal heart monitors and testing devices.

G

RCW 70.41.190 Refer to 1.1.1.9.

Immunization Record and Consent Form Signed consent forms and records noting the type of immunization performed which are not included in the patient’s medical record.

E

Instrument service records

180 Days – Hard Copy

Laboratory instrument service records

Life of Instrument+E

Laboratory superseded procedures (no longer in use)

E

Long term care facility patient records

E–after discharge or majority

42 C.F.R. §483.75

Mammography screening and/or diagnostic mammography services D 21 C.F.R. 900.12(e)(l)(i)

Master Patient Index Master index to patient health records.

A





Legal Citation

Methadone maintenance programs Clinical records on patients, including dates, quantities, batch or code mark of methadone dispensed.

E 21 C.F.R. §291.505*

Minors – Patient Medical Records Complete health records for minors.

G

RCW 70.41.190

Transfer Records Records related to patient transfer to and from the hospital. Information is in the Patient Medical Record.

E WAC 246-976-890; 42USC 1395cc(a)(1)(I) (ii)

Patient Health Records - Adults Complete health records for adult patients.

F

Patient Health Records - Minors Complete health records for minor patients.

G

Personal data to complete certificates of birth, death and report of fetal death

E

Psychiatric Records Psychiatric evaluations and treatment provided to patients.

F G

RCW 70.41.190

Quality assurance, inspections and equipment control records

E—electronic

Radiology – survey of removed radioactive implants

E 10 C.F.R. §35.415

Radiology – teletherapy units (NRC or state inspections)

Life of License

10 C.F.R. §35.647

Radiology – x-rays and MRI films

Current + E

Records of Hansen’s Disease Records related to the identification and treatment of Hansen’s Disease, which are not included in the patient’s medical record.

F G

Records of Sexually Transmitted Diseases Records related to the identification and treatment of sexually transmitted diseases, which are not included in the patient’s medical record.

F G

Records of Tuberculosis Records related to the identification and treatment of tuberculosis, including x-rays, which are not included in the patient’s medical record.

F G

WAC 246-100-211; RCW 70.28.010

Register of Births Register detailing all births occurring at the facility.

A

Register of Deaths Register detailing all deaths occurring at the facility.

A .

Register of Surgical Procedures Register detailing all surgical procedures performed at the facility.

A

Social service confidential case histories

D

Specimens – body fluid cytospin smear 6 months





Legal Citation

Specimens – body fluids

3 days

Specimens – CSF

7 days

Specimens – peripheral blood smears

14 days

Specimens – permanently stained slides – microbiology – AFB

A

Specimens – permanently stained slides – microbiology – blood culture

7 days

Specimens – permanently stained slides – microbiology – fungi smear

7 days

Specimens – permanently stained slides – microbiology – gram 7 days

Specimens – permanently stained slides – microbiology – O/P smear (positive)

E

Specimens – plasma

24-48 hours

Specimens – serum

3 Days

Specimens – transfusion service specimens

7 days post transfusion (or 10 days post cross-match)

Surgery log

E

Surgical pathology slides – accession log records

E

Surgical pathology slides – bone marrow reports

D

Surgical pathology slides – bone marrow smears

D

Surgical pathology slides – maintenance records

D

Surgical pathology slides – paraffin blocks

D

Surgical pathology slides – reports

D

Surgical pathology slides – slides

D

Surgical pathology slides – wet tissue

2 weeks after final report

Tumor Registry Files Records related to the identification and treatment of tumors that are not included in the patient’s medical record.

A RCW 70.54.240 (2)

1.0 Medical Staff 1.1 General


Legal Citations

Allied health professional files, non-employee

A

Bylaws A





Legal Citations

Constitution and Medical Staff Bylaws Records documenting the terms, conditions, and procedures by which the facility will operate.

A

Continuing education record

A

Medical staff applications, rejected

A

Medical staff committee records, including minutes, reports and other records Regulations require hospitals to maintain such records but do not specify retention periods.

A

Medical Staff Files Medical staff files including certification, credentials, and complaints.

A

Quality improvement/peer review reports

E

Residents, interns and fellows records

A


Legal Citations

Medical Staff Files Medical staff files including certification, credentials, and complaints.

A WAC 246-320-185

1.2 Residents & Fellows


Legal Citations

Applications E

29 C.F.R. §§1620.21 and 1602.14

Call and rotation schedules

D 42 C.F.R. §413.20

Official accreditation documents

A

Policy manual Current in GME + E

29 C.F.R. §1602.14

Post-graduate training files

A

5.0 Research


Legal Citations

Correspondence with investigators and sponsors

E

IRB records

E—after completion of research

40 C.F.R. §26.115

Research involving human subjects

E—after completion of research

40 C.F.R. §26.115

Research Papers – Published Published papers from medical staff.

A

Research Protocols E—after completion 40 C.F.R. §26.115





Legal Citations

of research Research Reports Reports related to medical research.

D

Sample Health System Attachment B –Certificate of Records Destruction Page 82.

RECORD RETENTION & MANAGEMENT Page 82 of 83

Certificate of Records Destruction 1. Purpose: To document record destruction activity. 2. Procedures:

a. Complete the Top Portion:

(1) Series Code and Series Title – Per Record Management policy. (2) Dates – Be sure to enter the beginning and ending dates of the material to be destroyed. (3) Media – Identify the media of the records being destroyed, i.e., paper, film, etc. (4) Cubic Feet – Enter the size of the material to be destroyed.

b. Destruction Approval Signatures:

(1) Signatures must be complete. (2) The Authorized Facility Approval is per facility policy.

c. Destruction:

(1) Records may be destroyed by an outside company or within a facility. (2) When the records are destroyed, the date is entered along with the method of destruction. (3) Destruction signatures:

(a) Records Destroyed By – This identifies who destroyed the record. (b) Witness – This identifies who witnessed the destruction of the record.

d. Distribution:

(1) Original Copy:

(a) Accompanies the record to be destroyed to the place of destruction. (b) After the destruction, the original copy is returned, complete with the destruction

signatures, to the Record Coordinator authorizing the destruction.

(2) Control Copy: Retains the control copy to verify that destruction has been done.

Sample Health System Attachment B –Certificate of Records Destruction Page 83.

RECORD RETENTION & MANAGEMENT Page 83 of 83

Certificate of Records Destruction Department Name: Department Contact:

Description, including type and quantity, of record series to be disposed of:

Dates Series Code

Series Title From To

Media

Cubic Feet

Signatures indicate approval for destruction of the above records:

Department Manager: Printed Name

Authorized Facility Approval: Printed Name

Signature X

Date Signature X

Date

The records described above were destroyed in the normal course of business pursuant to a proper retention schedule and destruction policy and procedure. All parties involved in this destruction process agree to maintain the confidentiality of the documents destroyed. Date of Destruction_______________ Method of Destruction: Burning Shredding Pulping Pulverizing Other ____________________________________ Records Destroyed By: Printed Name

Witness: Printed Name

Signature X

Date Signature X

Date

Company/Facility

Company/Facility